Health Home Enrollment and NEW YORK STATE DEPARTMENT OF HEALTH Information Sharing Consent Office of Health Insurance Programs For Use with Children Under 18 Years of Age Meee “This form must be used for cidren ess than 18 years of ag for emollient a2 Health Home. This form also ostines what and vith whom heath information canbe shared Please note children less than 18 years of age who are parents pregnant, and/or maid, and who are otherwise capable of consenting, should not use this form Rather they mustuse the Health Home Patient Information Shoring Consent frm (DOH 5035), Instructions for ParentGuardian/Leglly Authorized Representative: ‘Section £ ofthis form shoul be competed by the el’ Parent, Guardian, or Lealy Authorized Representative Legally Authored Representative forthe purpose of sharing hel informations defined 35's person or agency authorized by state rbl military or ther applicable a court order or consent tact on Eetalf ofa person forthe release of medial informaton. Lt all of he hil’ Rea providers who can share the child’ healt information The heath information they share may be rom before and after the dat you sign ths form. There providers an share hs information with eachother and with the cis ‘are management agen sted belo They canat give the chil information to other people unless you are, othe [asa they can. The cil can keep priate any inforntion about services the! the child consents for eutined In Section 2, incuding fail planing and emergency contraception, abortion, sexually {ansmited infection testing and treatment, HIV testing anctrestment HV prevention, prenatal ere labor and delivery series, drug and alohol restmert or ‘owl assul series I you consented or any of these services forthe child en you may have the authority to consent tthe eae of nfrmation egarding these services andcan ist the providers inthis action, Mate: he child may hav to consent to the release ofthis nfrmation a Section 2of this forms completed separatly bythe child wth the care manag. Children age 10 or older can consent to share or withhold formation regarding cettin types of protected services, In addition, if the child or adolescents specifically receiving services for mentl health or developmental (bites and is over the age 9f 12, the mental health and/or developmental disabiéties provider may ask te child or adolescent if they want their information disclosed Instructions for Cre Manager: Section 1 completed by the child arent, Guardian or Legally Authorized Representative tists all health providers who can hare the cis bealth information. ist the clés care management agency as 2 provider blow. Tse providers can share all hesth ntormation excep for any Taformaton about services the ld an sel-consent for ncluing fel lanring and emergency contraception abortion seal ens infection testing ‘nd veatment HIV testing and eater HY previo, prenatal car, aor and delivery series, drug and alcool treatment or sexual assault senvces. the Parent, Gordan or Legally Authorized Representative consented to abortion, sexually transite infection testing an treatment, HIV testing and rate. HIV preenton, or dug and alsholestment on behalf ofthe ci, information canon be released the child alse consents othe eles in Section 2, Cony the pig below as reeded tobe able st ll agreed to providers. this list needs tobe updated in the future ta either add or remove name. please hve the Paert/Guardsn/egally Authored Representative select either ADD or REMOVE, nial and date next to each naw entry or omission. The HHCM must also inital net to each change made, Instructions fo Participating Provider: if your name or agency sisted in Section 2, you may lease the chil’ health information except for any information bout series the child can el consent for, incuding family planning an emergency contraception, abortion, sexually ansmited infection testing and ‘treatment HIV testing and treatment IV prevention, prenatal are, abo and delivery services, dug and alcohol treatment. or sexual assault services. You may ‘only lease his information you ae given persion todo soin Section 2 ofthis form. I the Parent Guardian, or Legally Authorized Representative consented to borin, sexaly transmit infection esting and wearer HI testing and treatment, HI prevention or dug and aloha estment on behalf fhe cil Fnormaton can cnly be ‘leased the cil als consent tthe release in Section 2, Tyourecsive acon of Section 2 of his consent orm, plese review it L)rerore [. ‘Name of Provider ~Jaad ‘Saratoga Mentoring [remove Name of Provider Dasa Creme Name of Provides ase CJ | Bi tere _ DoWaTOT FORA age STEChildren's Health Homes of Upstate New York Thntonegurette tutte saettotsqatteoe naan 1dr eh a ie so ‘health information, as outtined in the Instructions above with each other for wen eee inact haonien mg tts et esos rt _ sos cha ota en EE Penge se program; + TABS/CHOICES: TABS/CHOICES is run by the New York State Office for People With Developmental Disabilities (OPWDD}. TABS/CHOICES collects and stores information for people wit intellectual and/or developmental disabilities (/0D) served through OPWDD's service system. 1 addition, the Health Home may need to share the chil’ information with the local Single Pint of Access (SPOA| to help the Wealth Home Gere Manager coordinate acess to needed mental health services. The SPO is able to see data under Mental Hygiene Law Section 41.05 and pursuant tothe authority of Sections 4.07 and 41.13. Permission i contact the SPOA can be provided onthe Provider page below. understand that this consent form takes the place of other Health Home information sharing consent forms I may have signed before on behalf of ‘the ehil This consent stays in place unt * Twithdcaw the child, oF + Thedtildis no longer eligible fora Health Home, oF + The Health Homes nolonger‘n business, or + The child becomes the age or situation to sel-consent (complete DOH-5055), [ean change this form at any time. IFT make changes, have tonal and date as indicated (or within the designated box). 1can always take back this consent on behalf ofthe child by contacting the Care Manager, Care Management Agency or Heath Home. 1 do not sign this consent form, [understand that the chil's information will not be shared. Dow sear aA peta