We are offering COVID-19 vaccines to current patients. Patients can schedule a vaccination through NYU Langone Health MyChart or the NYU Langone Health app. Learn more about the COVID-19 vaccine.
Patient Forms
Before receiving care as a patient at NYU 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:
- forms for your first visit
- forms for an inpatient visit
- forms for an outpatient visit
- forms for an observation visit
- forms for visits to a doctor’s office
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 NYU 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 NYU Langone facility, including a hospital, care location, or doctor’s office where the NYU 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 NYU Langone.
We encourage you to review these forms as well:
- Acknowledgment of Admission and Financial Information
- Acknowledgment of Patient Rights
- Health Care Proxy Information
- Notice of Privacy Practices Acknowledgment
- Patients’ Bill of Rights Information
- Parents’ Bill of Rights Information
Forms for Your Inpatient Visit
People coming for an inpatient stay need these forms and information:
- Acknowledgment of Admission and Financial Information
- Acknowledgment of Patient Rights
- Acute Inpatient Rehabilitation (if you are admitted to Rusk Rehabilitation)
- Advance Care Planning Information
- Efficiency and Quality Improvement Program
- Health Care Proxy Information
- Health Information Exchange (HIE) Fact Sheet and Consent Form
- Hospital Disclosure Form
- Inpatient, Outpatient, and Observation Visit Information
- Important Information for Medicare Patients
- Nondiscrimination Policy
- Notice of Privacy Practices
- Notice of Privacy Practices Acknowledgment
- Release of Records for External Appeal
- Statement of Patient Responsibilities
- Your Rights as a Hospital Patient
Forms for Your Outpatient Visit
People coming for an outpatient visit need the following forms and information:
- Acknowledgment of Admission and Financial Information
- Acknowledgment of Patient Rights
- Advance Care Planning Information
- Deciding About Health Care
- Health Care Proxy Information
- Health Information Exchange (HIE) Fact Sheet and Consent Form
- Hospital Disclosure Form
- Inpatient, Outpatient, and Observation Visit Information
- Nondiscrimination Policy
- Notice of Privacy Practices
- Notice of Privacy Practices Acknowledgment
- Patients’ Bill of Rights Information
- Release of Records for External Appeal
- Statement of Patient Responsibilities
Forms for Your Observation Visit
People coming for an observation visit need the following form:
Forms for Visits to a Doctor’s Office
If you are a patient who has not yet been to an NYU 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.
- FGP Financial Acknowledgment Form
- Health Information Exchange (HIE) Fact Sheet and Consent Form
- Notice of Privacy Practices
- Notice of Privacy Practices Acknowledgment
- Summary of Faculty Group Practice (FGP) Financial Policies
Additional Forms for Doctor’s Office Visits
Review these additional forms that you may need during the course of your treatment at NYU Langone:
- Authorization for the Use and Disclosure PHI (release of information and instructions)
- Credit Card Storage and Authorization Form
- Deaf and Hard of Hearing Questionnaire
- Financial Assistance Application
- Medicaid Non-Par Waiver
- Medicare Opt-Out Waiver
- New York State Assignment of Benefit
- Non-Par Financial Acknowledgment Form
- NYU Langone Health MyChart Adolescent Proxy Access
- NYU Langone Health MyChart Adult Proxy Access
- Patient Consent Form for Interpreter Services
- Patient Estimate Form
- Patient Information Change/Verification Form
- Proxy Access to the Online Medical Record of a Child Under 12 Years Old
- Workers Compensation/No Fault Insurance Registration Form
Notice of Privacy Practices in Other Languages
- Arabic (العربية)
- Bengali (বাংলা)
- Chinese (中文)
- Creole (kreol)
- French (Français)
- Greek (ελληνικά)
- Italian (Italiano)
- Korean (한국의)
- Polish (Polski)
- Portugese (Português)
- Russian (Pусский)
- Spanish (Español)