Forms
Adult New Patient
For adults (age 16+) with a new patient appointment
Pediatric New Patient
For children (age less than 16) with a new patient appointment
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.
Red Flags Rule - Information Letter & Payment Processing Form
Information explaining the federally-mandated "Red Flag" rules. Plus, form authorizing MCNT to process a patient's Medical Flex card, personal credit card, or personal check to pay for the services that they receive at the Medical Clinic of North Texas, P.A.
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
