Patient Resources

Health and Patient Forms

Providing care regardless of ability to pay.

For your convenience, Family Health Centers has important online patient forms for both existing and new patients available to download. Learn more about these important resources before you request an appointment.

View our Patient Forms

Downloadable Forms

Please download and complete the forms below and bring them with you when you visit Family Health Centers for your first appointment. If you have any questions, please contact us here or call (516) 295-3742.

New Patient Registration Packet

If you are a new Family Health Centers’ patient, you can download our patient registration form or request it from one of our staff members.

You may complete the new patient form before your appointment to make the registration process easier.

Fill out the patient form completely and bring it with you when you come in for your first appointment. If the form in your language is not available, please contact us.

Patient General Consent Form

If the form in your language is not available, please contact us.

RHIO Consent Form

If the form in your language is not available, please contact us.

Eligibility Determination for Sliding Fee Discounts

If the form in your language is not available, please contact us.

2020 Sliding Fee Scale

If the form in your language is not available, please contact us.

Privacy Notice of Privacy Practice Consent Form

If the form in your language is not available, please contact us.

Patient Rights and Responsibilities

As Family Health Centers’ patient, you have certain rights that provide you with basic protections when you are under our care.

The New York State Department of Health requires all health care facilities to inform those seeking health services about their rights and responsibilities. It is part of your registration as a patient and a key part of your health care plan.

Patient Bill of Rights for Adults 

Patient Bill of Rights for Parents

You can also learn more about your rights and responsibilities at any of our conveniently located Family Health Centers’ locations. If the form in your language is not available, please contact us.

NuHealth Privacy Notice

We are committed to maintaining the privacy of your protected health information.

Family Health Centers’ policies comply with the Federal HIPAA (Health Insurance Portability & Accountability Act) regulations.

Read this privacy notice that describes how your medical information may be used and disclosed and how you can access this vital information.

If the form in your language is not available, please contact us.

WIC Program

Children Medical Referral – Outreach

If the form in your language is not available, please contact us.

WIC – Authorization Form

If the form in your language is not available, please contact us.

Medical Referral Women – Outreach

If the form in your language is not available, please contact us.

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Our Health Centers Are Open!

On-site or TELEHEALTH appointments available by appointment only.

WHAT IS TELEHEALTH?

Telehealth allows the doctor to care for registered patients by phone when the provider and patient are not physically present with each other.

HOW TO REQUEST AN APPOINTMENT

Please call (516) 296-3742 or contact your local health center. You may also request an appointment via our online form.