Consent Forms

The following are Healthix Patient Consent Forms available in multiple languages. These can be tailored to an organization by personalizing the material with the organization name and logo. The content comes directly from the New York Department of Health and care should be given before editing the actual form. Healthix Patient Consent Forms enable patients to give consent to their providers – those who provide emergency services, such as a hospital emergency room or urgent care center; those who do not typically provide emergency care, such as a doctor’s office or clinic. If you have questions concerning these forms, please consult your organization’s administration or contact us at compliance@healthix.org

Consent Forms

Language For Emergency Providers
(grant, deny, grant Emergency only)
For Non-Emergency Providers
(grant, deny)
English download_red Download PDF download_green Download PDF
Arabic download_red Download PDF    download_green Download PDF
Bengali download_red Download PDF download_green Download PDF
Chinese download_red Download PDF  download_green Download PDF
Chinese (Traditional) download_red Not Available  download_green Download PDF
Creole download_red Download PDF download_green Download PDF
Czech download_red Download PDF download_green Download PDF
French download_red Download PDF download_green Download PDF
German download_red Download PDF download_green Download PDF
Greek download_red Download PDF download_green Download PDF
Hebrew download_red Download PDF download_green Download PDF
Hindi download_red Download PDF download_green Download PDF
Italian download_red Download PDF download_green Download PDF
Korean download_red Download PDF download_green Download PDF
Polish download_red Download PDF download_green Download PDF
Russian download_red Download PDF download_green Download PDF
Spanish download_red Download PDF download_green Download PDF
Ukranian download_red Download PDF download_green Download PDF
Urdu download_red Download PDF download_green Download PDF
Yiddish download_red Download PDF download_green Download PDF