Patient forms and notices

As a patient at MLK Community Healthcare, you have certain rights and responsibilities that are included in your healthcare

To receive the best possible care, it is important that you play an active role in your medical treatment. It is the responsibility of your healthcare team to include you in that process.

To learn about your rights as a patient, please review the notices below.

Notice of privacy practices
– EN
Aviso de prácticas de privacidad
– ES
Non-discrimination statement
– EN
Declaración de no discriminació
– ES
Patient rights & responsibilities
– EN
Derechos y responsabilidades del paciente
– ES

Financial assistance

Plain language financial assistance policy
– EN
Política de ayuda financiera de lenguaje sencillo
– ES
Financial assistance policy
– EN
Políticas de ayuda financiera
– ES
Financial assistance application form
– EN
Formulario de solicitud de ayuda financiera
– ES
Pricing transparency 2019
– EN
Pricing transparency 2020-2021
– EN
MLK Medical Group Clinics only: Financial assistance application form
– EN
MLK Medical Group Clinics only: Sliding Fee Discount policy
– EN

Billing & fair pricing

Pricing Transparency 2023-2024
– EN

Searchable pricing tool

Notice of charity care & fair pricing

Medical records release form

When you complete and sign this form, you give us permission to share your medical information with a specific healthcare provider.

Authorization for use or disclosure of patient health information
– EN
Autorización de uso o divulgación de información de salud de un paciente
– ES