Each form below opens as a fillable web page. You can type your answers right in the browser, then use the Print this form button to print a clean copy that includes everything you typed. Bring the completed form to your visit, fax it to 518-395-9431, or drop it off at any reception desk.
Your information stays in your browser. Hometown Health Centers does not receive or store anything you fill in here — submission happens when you bring or fax the printed form. If you’d rather fill it in by hand, just print the blank form and write your answers in.
If you need a form in a language other than English, free translation help is available — call us at (518) 370-1441.
Adult Patient Registration
For new adult patients. Captures contact information, household details, employment, insurance, and emergency contacts.
Pediatric Patient Registration
For new patients under 18. Includes parent and guardian information, household details, custody, insurance, and emergency contacts.
Consent to Disclose Personal Health Information
Authorizes Hometown to share your health information with people you choose (family members, other providers, etc.). You decide what’s shared and with whom.
Health Care Proxy
Appoints a trusted person to make health-care decisions for you if you’re unable to. New York State form — no lawyer or notary needed, just two adult witnesses.
Authorization for Release of Health Information
Use this form to request a copy of your medical or dental records, or to have them sent to another provider. Completed forms can be faxed to 518-395-9431 or dropped off at any reception desk.
Good Faith Estimate
If you don’t have insurance or are not using insurance, the federal No Surprises Act gives you the right to receive a Good Faith Estimate of expected charges before your visit. We provide an individualized estimate at scheduling — Read about your Good Faith Estimate rights.
Prefer a paper copy?
Three ways to get one
Pick one up at the front desk of any of our locations.
Call us at (518) 370-1441 and we’ll mail one to you.
If you need a form in a language other than English or Spanish, or in an alternative format (large print, screen-reader-friendly text), tell us — we’ll make it work.