Archived Questions and Answers

Member Forms

Health Home Patient Information Sharing Consent (DOH–5055)

1. Why was the first original DOH 5055 consent form revised?

The original consent form as a multi–entry consent form was difficult for some Health Homes and RHIOs to operationalize. Additionally, it was tied directly to the RHIO consent so that if a member withdrew their Health Home consent, it impacted the RHIO consent process. The form was modified to accommodate those RHIOs that use a single–entity consent. This separated the Health Home consent from the RHIO consent process except for the lead Health Home which still has its RHIO consent tied to DOH–5055. Health Home partners must still obtain a signed RHIO consent form to allow those partners direct access to the RHIO.

The original consent form was approved by all the appropriate

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2. Why was the DOH 5055 consent form revised again in December 2013?

In December 2013, the form was again revised to include language related to PSYCKES (Psychiatric Services and Clinical Knowledge Enhancement System for Medicaid), a HIPAA complain web application developed and overseen by The Office of Mental Health (OMH).

PSYCKES maintains all Medicaid claims and encounter data for clinical decision–making and quality improvement for individuals with any behavioral health service, diagnosis, or psychotropic medication. The New York State Department of Health (DOH) and Office of Mental Health (OMH) have a Memorandum of Understanding (MOU) through which PSYCKES can be accessed to obtain claims data for Medicaid enrollees with a mental health services, diagnosis, or psychotropic medication claim.

PSYCKES data can assist Health Homes to identify, evaluate, plan, coordinate, and manage Health Home members. This sharing of information will support the coordination of care by agencies serving the Health Home member. To support this, PSYCKES language was added to the DOH 5055 consent form. This latest updated version was posted on the DOH Health Home website in English and 7 translated languages in April 2014.

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3. Do all current Health Home members need to sign the revised DOH 5055 consent?

No. A revised consent (12/13) will only need to be resigned by members for whom access to PSYCKES is appropriate. Otherwise the current version of the DOH 5055 (11/12) consent remains in effect in the member´s record.

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4.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.

The current version (11/12) of the DOH 5055 does not allow for the sharing of PSYCKES information, only information from the RHIO. Once the revised DOH 5055 version 12/13 form is posted to replace version 11/12 PSYCKES, data can share between the Health Home and providers on page 3 of the consent approved by the member.

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