Get Ny Doh-5059 2019-2026

The NY DOH-5059 is an essential form for individuals eligible for the Health Home program under Medicaid in New York. This guide provides clear, step-by-step instructions to help you fill out the form accurately and efficiently online.

Follow the steps to complete the NY DOH-5059 online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the name of the Health Home with which you are engaging. This is the agency that provides the Health Home services you are opting out of.
3. Next, provide the name of your Medicaid Managed Care Plan. This helps to identify your current Medicaid coverage.
4. Proceed to the Attestation Statement section where you confirm that you have met with your Health Home care manager or their representative and that they have explained the Health Home program and its services to you.
5. In the ‘Reason for Opting Out’ section, briefly describe your reasons for choosing not to join the Health Home program at this time.
6. Review the acknowledgements carefully, as this section contains important information about opting out of Health Home services and potential alternative care options.
7. Print your name as the Medicaid client and provide your original signature to affirm your decision.
8. If applicable, enter the name and signature of your parent, guardian, or legally authorized representative.
9. Additionally, the Health Home Care Manager and Medicaid Managed Care Plan Representative must print their names and sign the form as well.
10. At the end, review all fields for accuracy, ensure all signatures are obtained, and then save changes, download, print, or share the form as necessary.

Take the next step in your care management journey by completing your documents online today.