Documents and Forms

Bassett Community Health Navigation Forms

Bassett CHN Disenrollment Summary
Bassett CHN HARP/HCBS MCO Approval Protocol
Bassett CHN Member Contact Sheet
Bassett CHN Member Rights & Responsibilities
Bassett CHN Monthly Referral Log
Bassett CHN Outreach Letter Template
Bassett CHN Referral Form
Bassett CHN System Access Request Form
Bassett CHN System Access Termination Form
Bassett Healthcare Network Computer Account Request Form
Bassett Medical Center-Confidentiality & Remote Access Agreement

Behavorial Health HCBS Forms

BH HCBS Eligibility Assessment
BH HCBS Plan of Care
BH HCBS Plan of Transportation Attachment

Department of Health Forms

DOH-5055 Health Home Patient Sharing of Information Consent
DOH-5058 Health Home Patient Withdrawal of Consent
DOH-5059 Health Home Opt Out Form
DOH Health Home Incident Reporting Form
DOH Outreach Letter Template
DOH-5234 Notice of Determination for Enrollment
DOH-5235 Notice of Determination for Disenrollment
DOH-5236 Notice of Determination for Denial of Enrollment
Hixny Forms

HIXNY Background on NYS RHIO Consent Policies
HIXNY Electronic Data Access Consent Form-Bassett
HIXNY Guide for Obtaining Patient Consent
HIXNY Patient Information Q&A
HIXNY Withdrawal of Consent Form-Bassett

Medicaid Restriction Exception Codes

Medicaid Restriction Exception Codes

Patient Actiavtion Measure (PAM)  Forms

Patient Activation Measure Survey (PAM-10)
PAM Consent
PAM Pre-Screening Tool


DSRIP 2.c.i Navigation Program Consent Form
DSRIP Navigation & PAM Opt Out
  • MyHealthy Decisons | Weight Loss Surgery - Sarah

    In talking with her doctor about her desire for a baby, Sarah learned that her weight could be a contributing factor in her ability to get pregnant. So, Sarah did her research and chose Bassett Healthcare's weight loss program to help her lose weight. A combination of coaching, diet and surgery hread more

    MyHealthy Decisions | Research into Kidney Health

    Bassett researchers have discovered a link between the frequent use of  a certain type of popular heartburn medications and an increased likelihood of serious kidney issues. While one might think that simply taking less of this medication could lower this risk, it is not always that easy for allread more

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