Patient Forms
New to Callen-Lorde? Make your first appointment online and complete your registration digitally by creating a MyChart account. If you would prefer to fill out a printed form, please call (212) 271-7200 for an email copy or come early to your appointment to complete it in person.
August 1, 2025: Please note we’ve updated our forms to include information regarding a new technology tool available during patient visits. (Note: Use is optional, and requires patient consent).
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 (Español)
- Patient Rights, Responsibilities & Financial Policies – Russian (Русский)
- Patient Rights, Responsibilities & Financial Policies – Chinese (简体中文)
- Patient Rights, Responsibilities & Financial Policies – French (Français)
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.
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.