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

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

Paciente Nuevo en Pediatría
Para niños menores de 16 años con cita

Medicare Annual Visit Questionnaire
For Medicare/Medicare Advantage patients only

Notice of Privacy Practices (HIPAA)
This Notice describes how medical information about you may be used and disclosed and how you can access this information

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

Financial Policy
Explains payment of services

Política Financiera
Esto explica sobre servicios de pago

General Consent
Authorizes USMD to asign benefits, patient consent to administer treatment, involvement of others in patients care and more...

The following 2 Forms are ONLY to be used for the Release of Medical Records TO and FROM USMD Physician Offices. They should not be used for USMD Hospital at Arlington or USMD Hospital at Fort Worth records.

Authorization to Release Medical Information TO USMD Physician Services
Form authorizing healthcare provider to release your medical information to USMD Physician Services.

Authorization to Release Medical Information FROM USMD Physician Services
Authorizes USMD Physician Services to release your medical information to specific entities.

Make the health system work better for everyone, inspiring people to live healthier lives.