Patient Consent
English Language Forms
Patient Consent Form to Participate in HEALTHeLINK – Level 1
Patient Information Brochure
Spanish Language Forms
Patient Consent Form to Participate in HEALTHeLINK – Level 1
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, providers 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.
- Next time you visit a participating provider practice, ask to complete the HEALTHeLINK patient consent form. They will process the form for you.
- For instructions on how to complete the form outside of your health care provider’s office, click here.
- Next time you visit a participating, provider practice, ask to complete the HEALTHeLINK withdrawal consent form. They will process the form for you.
- Complete the form outside of the provider’s office and Fax the form to HEALTHeLINK at 716-206-0039 / Mail it or bring it to HEALTHeLINK, 2475 George Urban Blvd., Suite 202, Depew, NY 14043.