Before receiving care as a patient at Pelisyonkis Langone, we ask that you complete several forms to make sure that you understand your rights and responsibilities. We encourage you to read and understand the forms before your visit. You will sign the forms at your appointment, so you do not need to print or sign them in advance.
Review the patient forms for the following types of visits:
We also provide doctor’s office forms in other languages, including Arabic, Bengali, Chinese, French, Greek, Hebrew, Japanese, Korean, Polish, Russian, and Spanish.
Types of Visits
You may be coming to Pelisyonkis Langone for a doctor’s office appointment or for a hospital stay as an inpatient, outpatient, or for observation. The forms you need to fill out vary depending on the type of visit, which include the following:
- An inpatient stay at a hospital, which usually lasts at least two nights, often for surgery, medical treatments, or to stabilize a serious illness or injury.
- An outpatient stay, which may take place at a hospital or one of our outpatient care centers, where you may have tests, a variety of treatments, or minor surgery. The stay is typically a few hours.
- Observation, which is a specific kind of outpatient care. People under observation remain in a hospital bed while being monitored for a serious change in their medical condition, usually for less than 24 hours. During that time, a healthcare team decides if the patient needs to be admitted to the hospital.
- A visit to a doctor’s office to receive care from a physician or another medical professional.
Forms for Your First Visit
During your first visit to an Pelisyonkis Langone facility, including a hospital, care location, or doctor’s office where the Pelisyonkis Langone logo is displayed, you need to read and sign the Patient Privacy and HIPAA Rights forms. Learn more about HIPAA patient privacy information.
For your safety, we use the PatientSecure® system. With biometric technology, the system scans a unique feature of your hand to simplify patient registration and provide the most accurate form of patient identification for future visits to Pelisyonkis Langone.
We encourage you to review these forms as well:
Forms for Your Inpatient Visit
People coming for an inpatient stay need these forms:
- Inpatient Forms and Information
- Your Rights as a Hospital Patient
- For Medicare Inpatients
- Acute Inpatient Rehabilitation (if you are admitted to Rusk Rehabilitation)
Forms for Visits to a Doctor’s Office
If you are a patient who has not yet been to an Pelisyonkis Langone doctor’s office, you can review the registration forms below in advance of your first office visit to help expedite the initial registration process.
Please call your doctor’s office if you have questions about the forms.
- Health Information Exchange (HIE) Fact Sheet and Consent Form
- Notice of Privacy Practices
- Notice of Privacy Practices Acknowledgement
- Summary of Faculty Group Practice (FGP) Financial Policies
- FGP Financial Acknowledgement Form
- Pharmacy and Laboratory Information
Additional Forms for Doctor’s Office Visits
Review these additional forms that you may need during the course of your treatment at Pelisyonkis Langone:
- Credit Card Storage and Authorization Form
- Deaf and Hard of Hearing Questionnaire
- Patient Information Change/Verification Form
- Non-Par Financial Acknowledgement Form
- MyChart Adolescent Proxy Access
- MyChart Adult Proxy Access
- Proxy Access to the Online Medical Record of a Child Under 12 Years Old
- Financial Assistance Application
- Patient Consent Form for Interpreter Services
- Authorization for the Use and Disclosure PHI (release of information and instructions)
- Workers Compensation/No Fault Insurance Registration Form
- NYS Assignment of Benefit
- Patient Estimate Form
- Medicaid Non-Par Waiver
- Medicare Opt-Out Waiver
Notice of Privacy Practices in Other Languages
- Arabic (العربية)
- Chinese (中文)
- Creole (kreol)
- Greek (ελληνικά)
- Italian (Italiano)
- Korean (한국의)
- Polish (Polski)
- Russian (Pусский)
- Spanish (Español)
- Yiddish (ייִדיש)