Doh 5058 withdrawal form-2026

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The document is a Withdrawal of Consent form from the New York State Department of Health for patients in the Health Home program. By signing this form, patients indicate their desire to exit the program and revoke permission for the sharing of their personal health information with Health Home providers and associated organizations. It outlines the implications of withdrawal, including that previously shared information remains with providers but cannot be accessed by Health Home partners after consent is withdrawn. The document also details legal protections for health information and provides guidance on future participation in the Health Home program.

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Click ‘Get Form’ to open the doh 5058 withdrawal form in the editor.
Begin by entering your name in the 'Print Name of Patient' field. This identifies you as the individual withdrawing consent.
Next, input your date of birth in the 'Patient Date of Birth' section to confirm your identity.
In the 'Signature of Patient or Patient’s Legal Representative' field, sign your name. If applicable, a legal representative can sign on your behalf.
If a legal representative is signing, ensure to fill out their name and relationship to you in the respective fields provided.
Finally, enter the date on which you are signing this form to complete the process.

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Versions	Form popularity	Fillable & printable
2018	4.7 Satisfied (26 Votes)
2014	4.6 Satisfied (31 Votes)

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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.