Patient Resources
Please find the following patient resources to help with medical record requests, grievances, information about our sliding fee scale, code of conduct, and notice of nondiscrimination and accessibility.
Medical Records Request
You can request a copy of your medical records by filling out the request form below and returning it to to Aria Roselle a.roselle@housingworks.org, or by calling 718-277-0386.
Medical Records Request [155kb, PDF] Minor's Consent to Parental Access to Health Information [124kb, PDF] Self Declaration of Minor's Ability to Independently Consent to Services [122kb, PDF]Grievance Form
Use this form to let us know about a complaint or concern (“grievance”) you have about your healthcare experience. You can return this form to Gillian Saunders at g.saunders@housingworks.org.
Grievance Form [120kb, PDF]Sliding Fee Scale
We help everyone regardless of ability to pay and source of payment. Please see our sliding scale fee information below.
Sliding Fee Scale Patient Guidelines in English [183kb, PDF] Sliding Fee Scale Patient Guidelines in Spanish [148kb, PDF] Sliding Fee Scale Application [144kb, PDF] Sliding Fee Scale Self Declaration Income in English [183kb, PDF] Sliding Fee Scale Self Declaration Income in Spanish [145kb, PDF]Code of Conduct
Please find our code of conduct available in English and Spanish.
Code of Conduct [131kb, PDF] Code of Conduct in Spanish [119kb, PDF]Notice Informing Individuals About Nondiscrimination and Accessibility
Notice of Nondiscrimination and Accessibility [1569kb, PDF]
Have questions about becoming a patient with us?
Regardless of insurance or ability to pay, we strive to meet you where you are and support you in and out of the doctor’s office.
Get in touch
Have questions? Don’t see what you need? We’re here to help. Check out our contact page for information on how to reach us.