Patient Forms

For your convenience, we have supplied our general patient forms below.  If you wish, click on the link below, print, complete the form, and bring it with you to your appointment.  Printing them, filling them out and bringing them with you will allow us to attend to your medical needs more quickly than completing them on your arrival.

Patient Rights, Responsibilities & Financial Policies

Please read these policies before filling out your registration forms.

• Patient Rights, Responsibilities & Financial Policies – English
• Patient Rights, Responsibilities & Financial Policies – Spanish
• Patient Rights, Responsibilities & Financial Policies – Russian

Registration and Consent Forms

• Registration and Consent Forms – English
• Registration and Consent Forms – Spanish
• Registration and Consent Forms – English (Large Print)
• Registration and Consent Forms – Spanish (Large Print)
• Registration and Consent Forms – Russian

HIPAA Release Forms

To request your medical records, please fill out a HIPAA Form and email to records@callen-lorde.org. You can also pick up and/or submit a form at any front desk. Please note this process can take 5-7 business days.

• HIPAA Release Form – English
• HIPAA Release Form – Spanish

For further assistance, please call our Medical Records department at (212) 271-7137.

Application for Income-Based Discount 

If your income information has changed since we last saw you, please fill out the following form.

Application for Income-Based Discount

Research Consent

Consent to Contact

Please fill out this consent form if you are interested in participating in research studies.

Telehealth Consent

Consent Form

Please fill out this consent form to receive telehealth services.