Form Library
The mission of Metro Community Health Centers, Inc. is to enable access to and provide high quality, well-coordinated, primary and specialty medical, dental, behavioral, rehabilitation, and ancillary health services.
Metro Community Health Centers, Inc. is committed to maintaining the privacy and confidentiality of your health information. We will only use or disclose (share) your health information as described in this Notice. Please review our Notice of Privacy Practices
Please download these forms and fill them out before your (first) appointment. You can bring these forms and deliver them to our front desk.
New Patient
Patient Intake Requirements
Patient Registration Form
Patient Medical history
Patient Consents Cover Letter
Patient Acknowledgement
Healthix Consent
Group Homes Authorization for Ongoing Release of PHI
General Consent for Treatment
Financial Agreement
Chronic Care Management (CCM)
Existing Patient
TELEHEALTH REQUEST
PRESCRIPTION RENEWAL REQUEST
PATIENT SURVEY 2024
General Consent for Treatment
Authorization to Release-Obtain PHI (Non -Group Home)
Group Homes Authorization for Ongoing Release of PHI
Chronic Care Management (CCM)
General Forms
COVID-19 Patient Consent and Immunization Screening Form
Fact Sheet for Patients - Moderna COVID-19 vaccine information
Sliding Fee Scale
Bronx
979 Cross Bronx Expressway Service Rd
Bronx, NY 10460
(718) 665-7565
Downtown Brooklyn
177 Livingston Street
Lower Level
Brooklyn, NY 11201
(718) 855-7707
Staten Island
2324 Forest Avenue
Staten Island, NY 10303
(718) 447-0200
Opening Hours
(Some telehealth services are available between 8am and 9pm)
Monday | 8:30 – 4:30 |
Tuesday | 8:30 – 4:30 |
Wednesday | 8:30 – 4:30 |
Thursday | 8:30 – 4:30 |
Friday | 8:30 – 4:30 |
Saturday | Temporarily Closed |
Sunday | Closed |
Contact Metro Health Community Service Centers
To make an appointment for new patients or additional services please call us at 855-MCHCNYC (855-624-2692). For all other questions, please fill out the form below.