Get Ny Doh-5058 2018-2026

Filling out the NY DOH-5058 form is a crucial step for individuals wishing to withdraw their consent from the Health Home program. This guide will walk you through the process of completing this form online with clear and supportive instructions.

Follow the steps to successfully complete your form.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred document editor.
2. Enter the name of the Health Home provider organization you are withdrawing from in the designated field.
3. Provide your full name in the 'Print Name of Patient' section so that it is clearly identifiable.
4. Fill in your date of birth to verify your identity in the 'Patient Date of Birth' field.
5. Sign the document in the 'Signature of Patient or Patient’s Legal Representative' section to confirm your decision.
6. Input the date of signing in the specified area to record when the consent was withdrawn.
7. If applicable, print the name of the legal representative and their relationship to you in the provided fields.
8. Review all the information for accuracy to ensure that there are no errors.
9. Once satisfied with the information entered, you can save the changes, download, print, or share the completed form as required.

Complete your NY DOH-5058 form online today to manage your Health Home consent efficiently.