Common Forms

General AIM Forms

AIM General Info/First Time Visit Form: English and Spanish.

myNYP/Patient Portal Signup Directions - First page is English, second is Spanish. This can be printed with an individualized confirmation code (in both English and Spanish) via the Profile page in iNYP, which makes things much easier for patients.

Advance Directive Forms

Health Care Proxy - In English and Spanish. Other language translations

Out of Hospital DNR - In English and Spanish. A single-purpose and easy to fill out order to ensure patient does not receive CPR at home. Consider MOSLT, below, for more robust advance care planning/do not hospitalize orders.

MOLST - For out-of-hospital DNR and do not hospitalize orders. Be sure to go through the appropriate checklist to ensure your form is completed correctly.

Clinical Referral Forms

PET Scan - Fillable PDF. Fax to number on top right of form.

Interventional Radiology - To request consultation and/or specific procedures. Fax to number on the form; for good measure, call the next day to ensure they call the patient.

Rehabilitation Medicine Forms - Includes vestibular rehab, cardiopulmonary rehab, seating and mobility clinic (formerly known as wheelchair clinic), and speech pathology. For PT or OT, please use the Allscripts order in the AIM order set. Fax to number on the form; for good measure, call the next day to ensure they call the patient.

Palliative Care Referral - For outpatients in need of palliative care services. Return via e-mail or fax, number on form.

Department of Health Letter Regarding Repeat CXR for Latent TB

When you have a patient with documented latent TB and a negative chest X-ray, there is no need to repeat a chest X-ray annually! This letter from the department of health can spare a lot of patients a lot of radiation.

Common Social Work Forms

M11q - You may fill out one or two of these!

NYS DOH Consumer Directed Personal Assistance Service (CDPAS) - For patients who want to hire their own HHA rather than using an agency.

Access-a-Ride/Paratransit Certification - Talk to Emilia Castrelos from social work if filling out one of these.