Doh 5058 withdrawal form-2025

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The document is a Withdrawal of Consent form from the New York State Department of Health for patients wishing to exit the Health Home program. By signing, patients revoke permission for their personal health information to be shared with Health Home providers and related organizations. It outlines the implications of withdrawal, including the retention of previously shared information by providers, legal protections for health information, and instructions for rejoining the program in the future.

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What is a consent document?

A document with important information about a medical procedure or treatment, a clinical trial, or genetic testing. It also includes information on possible risks and benefits. If a person chooses to take part in the treatment, procedure, trial, or testing, he or she signs the form to give official consent.

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