USMD|MCNT - Medical Clinic of North Texas

Forms

Adult NEW Patient
For adults (age 16+) with a NEW patient appointment

Adult CURRENT Patient
For exisiting adult patients (age 16+) with a pending appointment

Nuevo Paciente Adulto
Para nuevos pacientes adultos mayores de 16+ con cita

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.

Aviso de Practícas de Privacidad (HIPAA)
HIPAA requiere que todos los paciente completen sus formato. Describa como la información médica sobre usted deberá ser usada y como usted podrá tener acceso a esta información.

Red Flags Rule - Information Letter & Payment Processing Form
Information explaining the federally-mandated "Red Flag" rules. Plus, form authorizing USMD|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 USMD | Medical Clinic of North Texas PLLC.

Authorization to Release Medical Information TO USMD|MCNT
Form authorizing healthcare provider to release your medical information to USMD | Medical Clinic of North Texas PLLC.

Authorización para Divulgar Informacion Médica a USMD|MCNT
Esté formato autoriza al cuidado de salud a divulgar su información médica a USMD | Medical Clinic of North Texas PLLC.

Authorization to Release Medical Information FROM USMD|MCNT
Authorizes Medical Clinic of North Texas PLLC to release your medical information to specific entities.

Authorización para Divulgar Información Medica PARA USMD|MCNT
Autorizando a USMD | Medical Clinic of North Texas PLLC a divulgar su información médica a espeficicas entidades.

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

Petición de Corrección / Modificación de Registros Médicos
Esto te permite hacer una petición de corrección / modificacion de tus registros médicos

Financial Policy
Explains payment of services

Póliza Financiera
Esto explica sobre servicios de pago.

Deliver World-Class, Cost-Effective Patient Care.