Questions and Answers

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Member Forms

Health Home Patient Information Sharing Consent (DOH–5055)

  1. Is the Health Home consent form required?
  2. What are the goals of the Health Home consent (DOH–5055)?
  3. Who is responsible for obtaining consent - lead Health Home or Health Home provider?
  4. What will the signed Health Home consent (DOH–5055) allow?
  5. Will the RHIO consent form automatically allow a Health Home lead or any Health Home partner access to and sharing of Health Home member´s medical records/care plan stored in the RHIO?
  6. Doesn´t the PSYCKES consent form automatically allow a Health Home lead or any Health Home partner access to and sharing of Health Home member´s information stored in the PSYCKES.
  7. Will the OMH consent be needed if the member signs the revised DOH 5055 consent (version 12/13)?
  8. Can the member refuse to grant permission for the Health Home to access and share PSYCKES data?
  9. How do Health Homes access PSYCKES?
  10. What if an agency already has access to PSYCKES?
   Archived Questions
1. Is the Health Home consent form required?

Yes. The Health Home Patient Information Sharing Consent (DOH 5055) form is used by the Health Homes to allow for information to be shared between the Health Home and network partners approved by the member.

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2. What are the goals of the Health Home consent (DOH–5055)?

The ultimate goal of the Health Home consent form is to get the member into a Health Home, able to receive coordinated services based on a reasonable understanding of the member´s health care needs and medical history. The Health Home consent allows partners in the member´s Health Home team to share appropriate information to assist the member. The members served by Health Homes are chronically ill, often disenfranchised from even the fragmented system of health care they access and often have hierarchical concerns for food and shelter. They often have low trust of the system and low health literacy, both adding to the concerns of interacting with the health care system. This single consent signed opens the Health Home gateway of care to quickly meet critical care needs, build trust in accessing the system of care, and build self–reliance skills in managing health care conditions.

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3. Who is responsible for obtaining consent – lead Health Home or Health Home provider?

The lead Health Home is responsible for ensuring that consent is obtained, but may delegate this responsibility to a care management provider in its network. The Health Home consent can be found under Forms and Templates on the Health Home website by clicking here.

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4. What will the signed Health Home consent (DOH–5055) allow?

When a member signs the DOH 5055 consent form, s/he gives permission for the Health Home to obtain pertinent information needed to assess the member for services. In addition, the signed consent allows the Health Home care manager to share patient information with network partners and others approved by the member to formulate and maintain an appropriate plan of care.

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5. Will the RHIO consent form automatically allow a Health Home lead or any Health Home partner access to and sharing of Health Home member´s medical records/care plan stored in the RHIO?

No. A signed RHIO consent form will only allow access to the RHIO if the organization is a member of that local RHIO.

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6. Doesn´t the PSYCKES consent form automatically allow a Health Home lead or any Health Home partner access to and sharing of Health Home member´s information stored in the PSYCKES.

No. A signed OMH PSYCKES consent form will only allow access to PSYCKES for an authorized user who has applied and been given permission by OMH to access PSYCKES. The authorized user cannot share PSYCKES data with any agency or entity that the member has not approved through signing DOH 5055 consent.

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7. Will the OMH consent be needed if the member signs the revised DOH 5055 consent (version 12/13)?

No. Once the revised DOH 5055 consent (12/13) is completed and signed by the member, a separate OMH consent form is not needed for the Health Home to share information with its network partners approved by the member.

In order for a network partner to access PSYCKES database directly, they must be an ´authorized user´ of PSYCKES, and have the member sign an OMH PSYCKES consent.

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8.Can the member refuse to grant permission for the Health Home to access and share PSYCKES data?

Yes. The member has the right to refuse access to PSYCKES by the Health Home and others. Some members may not feel comfortable with providing access to all PHI provided through PSYCKES. The consent form must clearly indicate which entities have been declined access by the member.

It is the responsibility of the Health Home and/or care management agency to assure the member understands the benefits of providing consent, what information will be accessed and how information is shared.

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9.How do Health Homes access PSYCKES?

All Health Homes are required to be authorized users of PSYCKES. Information on becoming an authorized user can be found on the OMH website.

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10.What if an agency already has access to PSYCKES?

If an agency is already an authorized user of PSYCKES, the agency can continue to access PSYCKES data as long as an OMH PSYCKES consent has been signed by the member.

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