Forms

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)

Dental Forms

• Registration Packet
• Medical History Form

Authorization of Release of Health Information Forms:

• Release Form from an Outside Provider to any WYH location
• Release Form: From WYH Dental to an Outside Provider or Patient

Medical Patients

• Registration Packet
• Notice of Patient Privacy Practices
• Acknowledgement of Privacy Practice

Authorization of Release of Health Information Forms:

• Albany Health Center Patients
• Troy and Watervliet Health Center Patients
• Release Form from an Outside Provider to any WYH location
• Release Form from WYH to an Outside Provider or Patient

New Patients

• New Patient Welcome Packet

Opioid Treatment Program (OTP)

Authorization of Release of Health Information Forms:

• MMTP Patients
• Release Form from an Outside Provider to any WYH location
• Release Form from WYH to an Outside Provider

Outpatient Clinic (Formally FACTS Program)

Authorization of Release of Health Information Forms:

• FACTS Patients
• Release Form from an Outside Provider to any WYH location

Patient Satisfaction Survey

How Are We Doing?
Please complete our Patient Satisfaction Survey to give us your feedback!

• Patient Satisfaction – English
• Patient Satisfaction – Spanish

If you would prefer to complete the survey on paper, download the PDF versions below:

• PDF – Patient Satisfaction Survey – English
• PDF – Encuesta de Satisfacción de los Pacientes – Español

If you speak a language other than English or Spanish and need a translator to help you complete the survey, or if you have any questions or concerns, please contact our Patient Engagement Specialist at 518-465-4771, extension 5057.

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) 465-4771

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