Patient forms

New Patient Intake Forms
Accountable Care OrganizationDOWNLOAD
Non-Participating Disclosure & Consent (English)DOWNLOAD
Non-Participating Disclosure & Consent (Español)DOWNLOAD
NYS Out-of-Network Surprise Medical BillDOWNLOAD
Authorization for Release of Health InformationDOWNLOAD
Lumbar Patient Form
New Patient Lumbar FormDOWNLOAD
Cervical Patient Form
New Patient Cervical FormDOWNLOAD
New Patient Form (Dr. Feldstein's Office)
New Patient Form (Newborn to 18 years old)DOWNLOAD
New Patient Form (Adult)DOWNLOAD
Notice of Privacy PracticesDOWNLOAD
Authorization to Disclose Medical InformationDOWNLOAD
Authorization for Email CommunicationDOWNLOAD

Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information.

The following patient HIPAA forms can be found on Columbia University Irving Medical Center’s Office of HIPAA Compliance website.

  • Authorization to Disclose Medical Information
  • Notice of Privacy Practices (NOPP)
  • Patient Acknowledgement Form

For more information, please visit Columbia University Medical Center’s Health Insurance Portability & Accountability Act (HIPAA) Information page.

Email Communication
Email Communication FormDOWNLOAD
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