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New York Medicaid Health Home Opt-Out Form 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering your name in the 'Name of Medicaid Client' field. This identifies you as the individual opting out.
- In the 'Name of Health Home' section, specify the health home you are eligible for, if applicable.
- Next, provide the 'Name of Medicaid Managed Care Plan' to indicate which plan you are currently enrolled in.
- Fill out the 'Reason for Opting Out' section with a brief explanation of your decision.
- Sign and date where indicated as the Medicaid client. If applicable, have your parent, guardian, or legally authorized representative sign as well.
- Finally, ensure that both the Health Home Care Manager and Medicaid Managed Care Plan Representative sign and date their respective sections.
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