Patient Forms

For your convenience, please print and fill out all applicable forms and present them at check in when you arrive for your first visit.

Financial Responsibility

Financial Agreement and Assignment of Benefits

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HIPAA Contact Information

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Personal Representative Designation Form

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Records Release

Authorization for Release of Health Information (Including Alcohol/Drug Treatment and Mental Health Information) and Confidential HIV/AIDS related Information. DOH-5032.

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No Surprises Act

Right to Receive Good Faith Estimate

You have the right to receive a “Good Faith Estimate: explaining how much your medical care will cost.

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

  • You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
  • Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
  • If you received a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

Make sure to save a copy or a picture of your Good Faith Estimate
For questions or more information about your right to a Good Faith Estimate, visit or call 1-800-985-3059.

Protection Against Balance Billing

Learn more about patient rights in your region. Download the disclosure notice (PDF) for New York.

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