Patient Forms
Find a Health Center
Find a Service

Patient Forms

If you are a patient at the Institute for Family Health, you can access some of our registration and policy forms using the links below. We cannot accept these forms online or via email due to HIPAA regulations. You can print, fill out, and then bring the forms in to us at your next appointment.

1.   Medical Release Forms

a.       Authorization for the Institute for Family Health to Release Medical Information

i.   HIPAA Release to the Institute – English | Spanish 

b.       Request for Medical Information to be Sent to the Institute for Family Health

i.   HIPAA Release from the Institute – English | Spanish 

c.       Record Request

i.   DOH 5032 Medical Records Release Form – English | Spanish

2.   Notice of Privacy Practices

a.       Institute’s Privacy Practices – English | Spanish

3.   Registration Forms

a.       Patient Bill of Rights – English | Spanish

b.       Patient Responsibilities – English | Spanish

c.       How to Pay for Care – English | Spanish

d.       Summary on Advanced Directives – English | Spanish

e.       Voter Registration Forms – English | Spanish

4.   Consent Forms

a.       Health Care Proxy – English | Spanish

b.       Patient Consent and Notification Record  – English/Spanish