Forms for our current patients.
MINORS
Minors must be accompanied by a parent/guardian during the visit. If you are unable to attend the appointment, please have a trustworthy adult attend in your place, or if your minor is 16+ years old, they can be seen without a guardian. Email the corresponding completed form to [email protected].
Complete this form if another party not listed on the initial confidentiality form will be accompanying your minor.
If your minor is 16 years of age or above, they can be seen without a guardian as long as we are given prior consent.
RECORDS
To release your past medical records to our office: Please complete the form. It is REQUIRED that you provide your signature at the bottom of this form in order to process the request. Upon completion, please send this form to your current/previous doctors office and they will send your records to our office.
To release your medical records at this office to another doctor or to yourself: Please complete the form. It is REQUIRED that you provide your signature at the bottom of this form in order to process the request. Upon completion, please send this form to our office via email to [email protected] or fax to (972) 212-4270. Your request will be handled within 15 business days.
The following administrative fees apply for this service in accordance with the Texas Administrative Code. In addition to the amounts listed, charges will apply for the actual cost of postage, shipping, and delivery of records.
| Service | Charge to Patient |
|---|---|
| Retrieval Fee | $0 |
| Pages 1-20 | $25.00 |
| Pages 21-60+ | $0.50 per page |
DOCUMENTATION
If you are requiring documentation (for work, school, etc.) to be filled out by your physician, please email [email protected] or call (972) 943-0410 ext. 110. Your request will be reviewed and our back office administrator will reach out to you to discuss processing fees and if the request can be fulfilled.
If you have a deadline for the documentation, please allow ample time (minimum 2 weeks) for processing your request. Due to the high volume of requests, we ask for your patience and understanding.
