Patient Forms
At some point in your health journey at the Center, your provider or our Call Center may reference patient forms. Here is a list—organized by category—and subsequent contact information, just in case you need more help.
For Your Reference: Helpful Patient Forms
Medical Record Forms
Either before or after you book an appointment, you may be asked to fill out any number of these forms.
Patient Request for Access to Health Information (Web Form)
Solicitud Del Paciente Para El Acceso A La Información De Salud (Formulario Electrónico)
Patient Request for Access to Health Information (PDF)
Solicitud Del Paciente Para El Acceso A La Información De Salud (PDF)
Request To Amend Protected Health Information (PDF)
Request to Amend Protected Health Information (Web Form)
Solicitud De Enmienda De Información Médica Protegida (PDF)
Solicitud de Enmienda de Información Médica Protegida (Formulario Electrónico)
Third Party Authorization for Use or Disclosure of Health Information (PDF)
Third Party Authorization for Use or Disclosure of Health Information (Web Form)
Autorización a Terceros para Utilizar o Divulgar Información Protegida de la Salud (PDF)
Autorización a Terceros para Utilizar o Divulgar Información Protegida de la Salud (Formulario Electrónico)
Health Services Client Resources & Contact Information
Access our Health Services, Clinic, Pharmacy, and more with these direct lines. For phone calls, please pay attention to the option numbers provided here.
Pharmacy Call Center 323-993-7513
Mental Health, Clinic, and Insurance 323-993-7500 (Option 3)
Sexual Health 323-993-7500 (Option 2)
FollowMyHealth: Patient Portal
Health Services: General 323-993-7500 (Option 3)
Client Complaint and Grievance Procedure (PDF)
Procedimiento De Queja Y Reclamo Del Cliente (PDF)
Client Relations Form for Complaints, Compliments, etc. (Web Form)
Client Relations Form for Complaints, Compliments, etc. (PDF)
Formulario de Atención al Cliente para Quejas, Cumplidos, etc. (Web Form)
Formulario de Atención al Cliente para Quejas, Cumplidos, etc. (PDF)
Health Services Notices
Access our Health Services Notices here.
Client Bill of Rights and Responsibilities (PDF)
Declaración de Derechos y Responsabilidades del Cliente y del Paciente (PDF)
Notice of Privacy Practices (PDF)
Adviso
Notice of Nondiscrimination and ACA Section 1557 Grievance Procedure (PDF)
Aviso De No Discriminación Y Procedimiento (PDF)
Notice About Good Faith Estimates (PDF)
Notificación de Estimación de Buena Fe (PDF)
Registration Forms
Consult this list before your appointment, and reach out to our Health Services call center for additional questions.
Advance Health Care Directive
Consent For Treatment And Notice Of After Hours Coverage Availability (PDF)
Consentimiento Para Tratamiento Y Aviso Sobre La Disponibilidad De Cobertura Después De Horas Hábiles (PDF)
Authorization and Assignment (PDF)
Autorización Y Asignación (PDF)
Acknowledgment of Receipt of Notice of Privacy Practices (PDF)
Acuse De Recibo De La Notificación Sobre Las Normas De Privacidad (PDF)
Statement of WeHo Affiliation (PDF)
Declaracion De Afiliacion De West Hollywood (PDF)
HIV Supplemental Questionnaire (PDF)
Cuestionario Suplementario Sobre El Vih (PDF)
Mental Health Services Information (PDF)
Información Sobre Servicios De Salud Mental (PDF)
Health Information Exchange (HIE) Authorization (PDF)
Autorización de Intercambio de Información de Salud (PDF)
Ryan White HIV AIDS Program Annual Payment Cap
Pago Máximo Anual del Programa para el VIH-SIDA Ryan White
FTCA Coverage Notice: This health center receives HHS funding and has federal PHS deemed status with respect to certain health or health-related claims, including medical malpractice claims, for itself and its covered individuals. For more information, visit the Federal Tort Claims Act (FTCA) website.
Frequently Asked Questions About FollowMyHealth: Our Patient Portal
What is FollowMyHealth?
FollowMyHealth is your patient portal that allows you to access and manage your medical information online. With FollowMyHealth, you can get 24/7 access from any computer, smartphone, or tablet to:
- Update your address, contact, emergency and insurance information
- Send and receive secure messages to and from your provider
- View your test and lab results
- Request prescription refills
- Schedule appointments
- Receive email care reminders and clinic announcements
- Receive appointment reminders
- Set up accounts for your children or dependent adults
- Online bill pay
- Look up, download, and email selected vital signs, prescriptions, immunization history, and more!
- Meet with your provider through phone or video visits (Telehealth)
How do I sign up?
How do I log into FollowMyHealth?
Having technical problems?
Can I review my test results on the portal?
How do I send images to my provider via the portal?
How do I set up video visits via the portal?
How do I set up video visits via Zoom?