Commonly Used Forms
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.
Submit a Request for Medical Records Online
I AM THE PATIENT
I AM THE PATIENT'S REPRESENTATIVE
I AM AN ATTORNEY
When submitting a request online, please complete all required fields (marked with *). You will need to upload a copy of your government-issued photo ID. If you are unable to provide a photo ID, please visit one of our health center locations in person.
Requests will be processed within 5 to 10 business days from the time they are received. Requests are fulfilled by our medical records partner, Verisma.
QUESTIONS ABOUT ONLINE RECORDS REQUESTS?
Please call 866.602.2802 or email status@verisma.com
Advance Directives
Planning healthcare, end-of-life care, and more.
- New York Health Care Proxy form
- “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
Privacy Practices
- Notice of Patient Privacy Practices
- Notice of Patient Privacy Practices Part 2 – Substance Use Program
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.
Please note: Parents/guardians must complete an updated consent form every year for their child or children to continue receiving care through their SBHC.
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.
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.
Questions? Please call (518) 465-4771.