Forms

To download a form, Click on the applicable link below.

• Authorization for Disclosure of Health Information
• Authorization for Disclosure of Health Information (Spanish)
• Authorization to Receive Health Information
• Authorization to Receive Health Information (Spanish)
  
  
• Authorization for Duplication of Digital Images
• Authorization for Duplication of Digital Images (Spanish)
• Authorization for Release of Health Information (including alcohol-drug treatment and mental health information) and confidential HIV-AIDS Information (a NYS DOH required release form)
• Authorization for Release of Health Information (including alcohol-drug treatment and mental health information) and confidential HIV-AIDS Information (a NYS DOH required release form) (Spanish)
  
  
• Patient Request to Amend their Health Information
• Patient Request for an Accounting of Disclosures
• Patient Request to Restrict their Health Information
• Patient Request to Discuss Their Patient Health Information w/ a Designee
• Distributee Statement