Doh 5059-2026

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4 out of 5

34 votes

The document is a Health Home Opt-out Form from the New York State Department of Health for Medicaid clients. It allows eligible clients to formally decline participation in the Health Home program after discussing care management services with their care manager. The form includes sections for client and care manager signatures, as well as a note on how to access Health Home services in the future if desired.

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Click ‘Get Form’ to open the doh 5059 in the editor.
Begin by filling in your name and the name of the Health Home you are opting out from. This information is crucial for identifying your case.
In the 'Reason for Opting Out' section, provide a brief explanation of why you have chosen not to join the Health Home services. This helps document your decision.
Next, print your name or your legal representative's name clearly in the designated field.
Sign the form electronically using our platform’s signature feature, ensuring that both you and the care manager sign where indicated.
Finally, enter the date of signing to complete the form. Review all entries for accuracy before submitting.

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Versions	Form popularity	Fillable & printable
2019	4.4 Satisfied (36 Votes)
2012	4 Satisfied (34 Votes)

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What is the doh 4359 form?

NY DOH-4359 is a report form used by healthcare providers in New York State to document and report various health-related data to the New York State Department of Health.