Adult New Patient
For adults (age 18+) with a new patient appointment

Notice of Privacy Practice
Describes how medical information about you may be used and disclosed and how you can access this information.

Receipt of Notice of Privacy Practices
HIPAA requires all patients to complete this form.

Medical Release
Form authorizing healthcare provider to release your medical information to Medical Clinic of North Texas, P.A.

Medical Information Release
Authorizes Medical Clinic of North Texas, P.A. to release your medical information to specific entities.

Frequently Asked Questions
HIPAA as it relates to our patients.

Request for Correction / Amendment to Record
Allows you to request a correction / amendment to your medical record.

Know Your Benefits
This pamphlet can assist you in learning about your insurance benefits, including questions to ask your provider.

Financial Policy
Explains payment of services

Keryn Dias, M.D. is Board Certified by the
American Board of Obstetrics & Gynecology

3400 Matlock Rd.
Arlington, TX 76015
(817) 419-0569

100 Se Green Oaks Blvd.
Arlington, TX 76018
(817) 419-0585

507 S Carrier Pkwy.
Grand Prairie, TX 75051
(972) 237-2121