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NEW YORK STATE DEPARTMENT OF HEALTH MedicaidHealth Home Patient Information Sharing Concentrate of Health Homely signing this form, you agree to be in telehealth Home. To be in a Health Home, health

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Who needs name of health home?

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Individuals who are applying for or enrolling in a health home program.

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Healthcare professionals or administrators responsible for collecting and maintaining patient information.

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What is name of health home?

The name of the health home is XYZ Health Home.

Who is required to file name of health home?

The health home administrator is required to file the name of the health home.

How to fill out name of health home?

The name of the health home can be filled out by submitting the required form online or by mail.

What is the purpose of name of health home?

The purpose of the name of the health home is to identify the specific health home and its services.

What information must be reported on name of health home?

The name of the health home, address, contact information, and services provided must be reported.

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