ºÙºÙÊÓƵ

Before receiving care as a patient at ºÙºÙÊÓƵ, we ask that you review or sign several forms to make sure that you understand your rights and responsibilities.

Prior to your hospital stay or doctor’s visit, forms and notices you need to review or sign are posted in your . If you are a patient at ºÙºÙÊÓƵ and do not have a MyChart account, you can . We also recommend that you download the ºÙºÙÊÓƵ Health app to access your MyChart account from your mobile device.

Download the ºÙºÙÊÓƵ Health App on the App Store or Google Play.

Ìý

You can read and sign forms in advance of your visit in order to expedite your check-in process.

Review the patient notices and information for the following types of visits:

• information for your first visit
• information for your hospital visit
• information for an observation visit
• information for visits to a doctor’s office

Request and Share Your Medical Records

You can request your medical records and share them with anyone you authorize, such as a healthcare professional, family member, or legal professional. Learn more about requesting your medical records.

Types of Visits

You may be coming to ºÙºÙÊÓƵ 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 more than 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 ºÙºÙÊÓƵ facility, including a hospital, care location, or doctor’s office where the ºÙºÙÊÓƵ logo is displayed, you need to read and sign the Patient Privacy and HIPAA Rights forms. This information, along with our Health Information Exchange Fact Sheet and Consent Form, is also available in multiple languages. 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 ºÙºÙÊÓƵ.

Information for Your Hospital Visit

People coming for a hospital visit may need to review these notices and information:

• Acute Inpatient Rehabilitation Privacy Act (if you are admitted to Rusk Rehabilitation)
• Advance Care Planning
• Health Information Exchange (HIE) Fact Sheet and Consent Form
• Hospital Disclosure Form
• Inpatient, Outpatient, and Observation Visit Information
• Nondiscrimination Policy
• Notice of Privacy Practices
• Statement of Patient and Visitor Responsibilities
• :

We also provide hospital forms in several languages, including Chinese, English, Haitian–Creole, Italian, Korean, Russian, and Spanish.

Notice for Your Observation Visit

People coming for an observation visit need to review the following notice:

• Medicare Outpatient Observation Notice

Forms for Visits to a Doctor’s Office

If you are a patient who has not yet been to an ºÙºÙÊÓƵ 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
• 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 ºÙºÙÊÓƵ:

• 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
• ºÙºÙÊÓƵ Health MyChart Proxy Access
• Patient Consent Form for Interpreter Services
• Patient Information Change/Verification Form
• Workers Compensation/No Fault Insurance Registration Form