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
| Language | For Emergency Providers (grant, deny, grant Emergency only) |
For Non-Emergency Providers (grant, deny) |
|---|---|---|
| English |  Download PDF |
 Download PDF |
| Albanian |  Download PDF |
Download PDF |
| Arabic | Download PDF |
Download PDF |
| Bengali | Download PDF |
Download PDF |
| Chinese | Download PDF |
Download PDF |
| Chinese (Traditional) | Download PDF |
Download PDF |
| Creole | Download PDF |
Download PDF |
| Czech | Download PDF |
Download PDF |
| French | Download PDF |
Download PDF |
| German | Download PDF |
Download PDF |
| Greek | Download PDF |
Download PDF |
| Hebrew | Download PDF |
Download PDF |
| Hindi | Download PDF |
Download PDF |
| Italian | Download PDF |
Download PDF |
| Korean | Download PDF |
Download PDF |
| Polish | Download PDF |
Download PDF |
| Portuguese | Download PDF |
Download PDF |
| Russian | Download PDF |
Download PDF |
| Spanish | Download PDF |
Download PDF |
| Ukrainian | Download PDF |
Download PDF |
| Urdu | Download PDF |
Download PDF |
| Yiddish | Download PDF |
Download PDF |
| Consent Forms | Links to Downloadable Forms |
|---|---|
| Minor One Time Consent | Download Form (PDF) |
| One-to-One Exchange: For Providers | Download Form (PDF) |
| One-to-One Exchange: For Health Plans | Download Form (PDF) |
| Consent Withdrawal | Download Form (PDF) |
| Deny All Consent (for Public Use) | Download Form (PDF) |
| Withdrawal of Deny All Consent (for Public Use) | Download Form (PDF) |
