Forms

Commonly Used Forms

• Release of Health Information

IMPORTANT: The Release of Health Information form is to be used for ALL Whitney Young Health programs and services, including: Medical, Dental, Behavioral Health, and Opioid Treatment/Addiction Treatment.

Advance Directives

Planning healthcare, end-of-life care, and more.

• Advance Care Planning
• New York Health Care Proxy form
• New York Living Will form
• Organ Donation: Closing the Racial and Ethnic Gap
• “Deciding about Health Care – A Guide for Patients and Families”
• Information on NYS Health Care Proxy Law – page includes links to health care proxy forms in multiple languages
• MOLST (Medical Orders for Life Sustaining Treatment)

Registration Packet

• Registration Packet

Dental Forms

• Medical History Form

Medical Patients

• Notice of Patient Privacy Practices
• Acknowledgement of Privacy Practice

School-Based Health Centers (SBHC)

A parent or guardian must fill out the form below for their child or children to receive care at any of our School-Based Health Centers (SBHC). Please submit the completed form to the school your child or children will be attending.

• School-Based Health Center Enrollment Packet

Please note: Parents/guardians must complete an updated consent form every year for their child or children to continue receiving care through their SBHC. Please use the form below to update consent.

• School-Based Health Center – Annual Update

If you have questions about availability of services for your child or children, please contact Whitney Young Health’s School-Based Health Center program at (518) 573-2556.

Sliding Fee Scale Discount

To qualify for Whitney Young Health’s Sliding Fee Scale Discount, please fill out the form below and provide the required documentation listed in the application.

The form and required documentation can be brought in to Registration Staff any of our health center locations or emailed to registration@wmyhealth.org.

• Sliding Fee Scale Discount Application

Whitney On Wheels (WOW)

Below are the forms you must fill out for yourself or for your child/children to receive medical care on our mobile health unit, Whitney on Wheels (WOW).

Please submit the completed form(s) to the representative of the sites WOW currently visits.

• Whitney on Wheels Enrollment Packet – Adult Form
• Whitney on Wheels Enrollment Packet – Child Form
• Whitney On Wheels – Annual Consent Update – Child

Questions? Please call (518) 465-4771.

WIC (Women, Infants & Children)

• WIC Medical Referral Form