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 patien appointment.
Full Packet | Required Pages Only

Notice and Receipt 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.

Financial Policy
Explains payment of services

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.

Immunization Registry
Consent Form
Allows schools to verify records

Para obtener estos formularios en español, OPRIMA AQUÍ.

Shannon C. Baker, M.D. is Board Certified by the
American Board of Family Medicine