Patient Forms - Los Angeles LGBT Center

Health Services

The Los Angeles LGBT Center is one of the few Federally Qualified Health Centers with providers who specialize in primary care for lesbian, gay, bisexual, and transgender people and people living with HIV.

You can always talk candidly and comfortably with your doctor and other providers, knowing that you’re receiving leading-edge care, regardless of your ability to pay.

Patient Forms

Health Services Patient Forms

Meet Locke

The Center helped me see how my life could be different.

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Advance Health Care Directive

Consent For Treatment And Notice Of After Hours Coverage Availability

Consent for Treatment and Notice of After Hours Coverage Availability (Spanish)

Authorization and Assignment

Authorization and Assignment (Spanish)

Client Relations Form (English)

Client Relations Form (Spanish)

Client Complaint and Grievance Procedure (English)

Client Complaint and Grievance Procedure (Spanish)

Client Bill of Rights and Responsibilities

Client Bill of Rights and Responsibilities (Spanish)

Notice of Nondiscrimination and ACA Section 1557 Grievance Procedure

Notice of Nondiscrimination and ACA Section 1557 Grievance Procedure (Spanish)

Acknowledgment of Receipt of Notice of Privacy Practices

Acknowledgment of Receipt of Notice of Privacy Practices (Spanish)

Notice of Privacy Practices

Notice of Privacy Practices (Spanish)

Statement of WeHo Affiliation

Statement of WeHo Affiliation (Spanish)

HIV Supplemental Questionnaire

HIV Supplemental Questionnaire (Spanish)

Mental Health Services Information

Mental Health Services Information (Spanish)