USMD|MCNT - Medical Clinic of North Texas

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

Medical Oncology New Patient
For Dr. C.K. Wang or Dr. Revathi Angitapalli patients 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.

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.

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

Authorization to Release Medical Information TO USMD IMAGING CENTER FOR BREAST HEALTH
Form authorizing healthcare provider to release your medical information to USMD Imaging Center for Breast Health (USMD Physician Services).

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

Financial Policy
Explains payment of services

 

Deliver World-Class, Cost-Effective Patient Care.