Adult New Patient
For adults (age 18+) with a new patient appointment
Full Packet | Required Pages Only

Pediatric New Patient
For children (age less than 18) with a new patient appointment
Full Packet | Required Pages Only

Receipt and Notice of Privacy Practices (HIPAA)
HIPAA requires all patients to complete this form. Describes how medical information about you may be used and disclosed and how you can access this information.

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

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

HIPAA Patient Education - 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

Para obtener estos formularios en español, OPRIMA AQUÍ.

Rupal Chiniwala, M.D. is Board Certified by both the American Board of Internal Medicine and the American Board of Pediatrics.

University of Cincinnati Medical Center, Cincinnati, Ohio

1804 E Hebron Pkwy.
Carrollton, TX 75007
(972) 939-1977

Internal Medicine & Pediatrics
Board Certified by both the American Board of Internal Medicine and the American Board of Pediatrics.