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Patient Forms and Information

Planned Parenthood of Greater New York cares about the quality of information and service that you receive at our health centers. See below for patient forms and information. 

 

Request for Medical Records

To transfer your records from PPGNY to another health facility, please fill out this form and mail or bring it to PPGNY.

Patient Bill of Rights

Read PPGNY's Patient Bill of Rights in English and Spanish to find out about your legal rights as patients.

Statement of Commitment to Equitable Care

Planned Parenthood of Greater New York actively works toward being a multicultural, inclusive, and anti-racist organization where staff, patients, and community of all identities can thrive. 

HIPAA Privacy Policy

Read PPGNY's HIPAA Privacy Policy to learn about our privacy practices concerning health information about our patients.

Financial Assessment and Patient Contact Form

If you are a new patient of the Corning, Elmira, Hornell, Ithaca, or Watkins Glen health centers, please download the patient intake form at the link below, complete in advance, and bring to your visit.

Family Planning Benefit Program Application Instructions

Family Planning Benefit Program Application

Instructions for Patients Having Procedures

Medication Abortion

Surgical Abortion

Telehealth Medication Abortion

No Surprise Medical Bills:

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the cost of services.

  • You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency services. This includes related costs like medical tests and prescription drugs.
  • If you schedule your appointment at least 3 days in advance, make sure your provider offers you a Good Faith Estimate in writing at least 1 business day before your appointment. You can also ask your provider for a Good Faith Estimate before you make an appointment. 
  • If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute it.
  • Make sure to save a copy or picture of your Good Faith Estimate. 

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