Here are forms that pertain to your care. Please note that the forms are in Adobe PDF format, and you will need to have the free Adobe Acrobat Reader software installed on your computer. You can download the software here.

Release Forms

• Authorization for the Release of Medical Information (English)
• Authorization for the Release of Medical Information (Spanish)
• Authorization to Communicate PHI (English)
• Authorization to Communicate PHI (Spanish)
• Revocation of Authorization to Communicate Protected Health Information

Request Forms

• Amendment of PHI Request Form
• Accounting of Disclosures Request Form
• Request for Alternative Communications
• Request to Restrict Uses and Disclosures of Protected Health Information to Health Insurance Plans
• Westmed Family Access Form (Patient Portal Caregiver Access Authorization Form) -English
• Westmed Family Access Form (Patient Portal Caregiver Access Authorization Form) – Spanish
• Request to Restrict Uses and Disclosures of PHI

Questions to Ask

• Diagnostic Form
• Health Problem Form
• Medications
• Surgical Procedure Form

Preventive Health Guidelines

• Preventive Health Guidelines For Men
• Preventive Health Guidelines For Women

Healthcare Proxy/Advanced Directive

• New York State Health Care Proxy Form (English)
• New York State Health Care Proxy Form (Spanish)
• Connecticut Advanced Directive Form

Other

• Transfer Medical Records To Westmed
• Westmed HIPAA Privacy Notice
• Westmed Code of Conduct
• Westmed Compliance Plan
• Opioid Pain Medication Facts – Surgical
• Opioid Pain Medication Facts – Non-Surgical

Please note that we may disclose your medical information to contractors, agents and other business associates who need the information in order to assist us in obtaining payment or carrying out our business operations. For example, we may share your medical information with a billing company that helps us to obtain payment from your insurance company. Another example is that we may share your medical information with an accounting firm, law firm or risk management organization that provides professional advice to us about how to improve our health care services and comply with the law. If we do disclose your medical information to a business associate, we will have a written contract to ensure that the business associate also protects the privacy of your medical information.