Patient Consent

English Language Forms
Patient Consent Form to Participant in HEALTHeLINK – Level 1
Patient Exclusion Form
Patient Information Brochure

Spanish Language Forms
Patient Consent Form to Participate in HEALTHeLINK – Level 1
Patient Exclusion Form
Patient Information Brochure

Arabic Language Form
Patient Consent Form to Participate in HEALTHeLINK – Level 1
Patient Information Brochure

Bengali Language Form
Patient Consent Form to Participate in HEALTHeLINK – Level 1

Burmese Language Form
Patient Consent Form to Participate in HEALTHeLINK – Level 1

Karen Language Form
Patient Consent Form to Participate in HEALTHeLINK – Level 1

Nepali Language Form
Patient Consent Form to Participate in HEALTHeLINK – Level 1

Polish Language Forms
Patient Consent Form to Participate in HEALTHeLINK – Level 1
Patient Information Brochure

Russian Language Forms
Patient Consent Form to Participate in HEALTHeLINK – Level 1
Patient Information Brochure

Somali Language Form
Patient Consent Form to Participate in HEALTHeLINK – Level 1

Swahili Language Form
Patient Consent Form to Participate in HEALTHeLINK – Level 1

Tigrinya Language Form
Patient Consent Form to Participate in HEALTHeLINK – Level 1

 

By granting consent, physicians treating you will have access to important clinical information about you that could be unavailable otherwise. For more specific information, visit the Consent Frequently Asked Questions.

There are two ways you can establish and communicate your intentions regarding consent:
  1. Next time you visit a participating physician practice, ask to complete the HEALTHeLINK patient consent form. They will process the form for you.
  2. For instructions on how to complete the form outside of your health care provider’s office, click here.
If you have already consented to participate in HEALTHeLINK and you wish to withdrawal consent, you can do so by completing one of the two following steps:
  1. Next time you visit a participating physician practice, ask to complete the HEALTHeLINK withdrawal consent form. They will process the form for you.
  2. Complete the form outside of the physician’s office and Fax the form to HEALTHeLINK at 716-206-0039 / Mail it or bring it to HEALTHeLINK, 2568 Walden Ave, Suite 107, Buffalo, NY 14225