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.
Registration and Consent Forms
Patient Rights, Responsibilities & Financial Policies
- Patient Rights, Responsibilities & Financial Policies – English
- Patient Rights, Responsibilities & Financial Policies – Spanish
HIPAA Release Forms
To request your medical records, please fill out a HIPAA Form and email to firstname.lastname@example.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.
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.
Please fill out this consent form if you are interested in participating in research studies.
Please fill out this consent form to receive telehealth services.