WIHD Registration Packet

To facilitate the registration process for outpatient services at WIHD, the registration packet is now available electronically in Adobe PDF format. Before an initial appointment at WIHD, a registration packet needs to be completed; forms can be downloaded, completed, and returned to the appropriate WIHD department prior to the appointment. The forms are fillable using Adobe® Reader®.

PLEASE NOTE: In order to view the pdf files you need to have Adobe® Reader®. If you don't have Adobe® Reader® you can download it from http://www.adobe.com/products/acrobat/readstep2.html

1. REGISTRATION FORM - This form provides the Westchester Institute for Human Development with basic information about the person receiving services. It also asks to identify parents or guardians, as well as information needed for billing purposes.
   Registration Form (PDF)



2. NOTICE OF PRIVACY PRACTICES FORM - This form is to acknowledge that you have received a Notice of Privacy Practices, which is included in this packet.
   Notice of Privacy Practices Form (PDF)
   
   Notice of Privacy Practices - Document (PDF)



3. FINANCIAL STATEMENTS FORM - Complete sections 1, 2, and 4. If you are covered by Medicare, please complete section 3 also.
   Financial Statements Form (PDF)



4. PROTECTED HEALTH INFORMATION - This form authorizes the Westchester Institute for Human Development to release health information to the individuals and/or organizations designated by you. Information from medical care is privileged and cannot be released without this form.
   Protected Health Information Form (PDF)
   

Adult Health Services
Westchester Institute for Human Development
Cedarwood Hall Room 221
Valhalla, NY 10595-1681
914.493.8170

Child Development Services
Westchester Institute for Human Development
Cedarwood Hall Room 300B
Valhalla, NY 10595-1681
914.493.5246

Speech and Hearing Center
Westchester Institute for Human Development
Cedarwood Hall Room 431
Valhalla, NY 10595-1681
914.493.7294

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