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Patient Forms

Patient Consent Forms

The General Consent for Treatment form is completed at the time of registration at Westchester Medical Center, and is available here for those who wish to review the document.

Request for Medical Records

To obtain a copy of your medical records or to request that they be shared with another healthcare provider or other organization, please complete and submit the following form that authorizes Westchester Medical center to use or disclose your Personal Health Information.

Making Your Healthcare Wishes Known

The following form is available to download online and may also be picked up at Westchester Medical Center. If possible, you should bring this form with you at admission in order to facilitate access to it if the need arises.

What is a Health Care Proxy?
The New York State Health Care Proxy Law allows you to appoint someone you trust – a family member or close friend, for example – to decide about treatment only if you lose the ability to decide for yourself. You can appoint someone by signing a form called a Health Care Proxy, thereby designating them as your "health care agent" or proxy You can give the person you select as little or as much authority as you wish. You can allow your health care agent to make decisions about all of your health care or only about certain treatments. You may also give your health care agent specific instructions that he or she has to follow so they can make sure your health care team adheres to your wishes and applies them appropriately as your medical condition changes. Hospitals, doctors and other health care providers must follow your agent's decisions as if they were your own.

What Is a Do Not Resuscitate Order?
Under New York State law, all adult patients can request a Do Not Resuscitate (DNR) Order. Once signed, this form is placed in the patient's chart and instructs the medical staff not to try to revive the patient if breathing or heartbeat has stopped. This means the medical staff will not initiate heart or open chest massage and will not initiate ventilation in the event of a cardiac or respiratory arrest.

Is a Health Care Proxy the Same as a Living Will?
No. A Living Will is a document that provides specific instructions about health care treatment. It is generally used to declare wishes to refuse life-sustaining treatment under certain, specified circumstances.

In contrast, the Health Care Proxy allows you to choose someone you trust to make treatment decisions on your behalf. The Health Care Proxy is just as useful for decisions to receive treatment as it is for decisions to stop treatment. Unlike a Living Will, a Health Care Proxy does not require that you know in advance all the conditions that might arise or all decisions that need to be made. Instead, your health care agent can interpret the circumstances and make decisions based on your wishes. If you complete a Health Care Proxy form but also have a Living Will, the Living Will provides instructions for your health care agent and will guide his or her decisions.

Where Should I Keep the Proxy Form?
Always keep your Health Care Proxy form in a safe, accessible place. Give a copy to your agent, your doctor and any other family member(s) or close friend(s) you want. You should also keep a copy in your wallet or purse along with other important papers. A copy of your Living Will and healthcare proxy form will be requested when you are admitted to the hospital.

Appointing a health care agent is a serious decision. Make sure you talk about it with your family, close friends and your doctor. Initiate your Health Care Proxy in advance, not just when you are planning to enter the hospital. If you wish, our Patient Representatives will provide you with a Health Care Proxy and Living Will forms, explain their significance, and assist you in making your decision.

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