Patient Forms

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Patient Forms

Many of these forms can be submitted electronically to Open Door. Please see the links provided.

Patient Registration Form
click here

Patient Bill of Rights
click here

HIPAA Statement Acknowledgement Form
click here

Authorization to Release Medical Information (Medical Records)
click here

Treatment and Assignment of Others to Accompany Minors-Medical
click here

Treatment and Assignment of Others to Accompany Minors-Dental
click here

Health Care Proxy
click here

Living Will
click here

Electronic Data Access Consent
click here

After-Hours Medical Assistance:
If you need urgent medical advice or care when the center is closed, you can reach our on-call provider 24/7 by calling:

914-OD-CARES
914-632-2737

Quick Links

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Open Door is proud of the local and national recognition it has received:

This health center receives HHS funding and has Federal Public Health Service (PHS) deemed status with respect to certain health or health-related claims, including malpractice claims, for itself and its covered individuals. In accordance with Federal law and U.S Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, age, disability, religion, sex, and familiar status. (Not all prohibited bases apply to all programs). To file a complaint of discrimination, write UDSA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TDD).