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

Richard Penny, M.D. is Board Certified by the
American Board of Internal Medicine

Dr. Penny was named as a Top Doc in the Dallas / Fort Worth metroplex by his colleagues. He was recognized in the April 2006 edition of Fort Worth Texas Magazine.

Dr. Penny was also recognized in the Best Doctors in America database. The database was comprised of over 32,000 of his peers. He was recognized in July 2005.

6205 Westcreek Dr.
Fort Worth, TX 76133
(817) 263-0962

2603 West Berry St.
Fort Worth, TX 76109
(817) 923-8259

6244 Lake Worth Blvd.
Lake Worth, TX 76135
(817) 238-0385

4520 Western Center Blvd.
Haltom City, TX 76137
(817) 514-8063

9625 White Settlement Rd.
Fort Worth, TX 76108
(817) 367-3469

1317 S. Main
Weatherford, TX 76086
(817) 594-5771

4520 Western Center Blvd.
Haltom City, TX 76137
(817) 514-8063

1050 E. Hwy 377
Granbury, TX 76048
(817) 578-3120