Patient Forms

Thank you for choosing Health Services of North Texas for your medical and wellness needs. You are on your way to getting connected to a team of providers that will help you get to your very best healthy. To get started, we need to gather some information about you and your medical history along with some other information that will help us provide you with the very best healthcare experience possible and make check-in a breeze! Completing the forms 24 hours before your appointment is best.

We realize there are some questions that seem unnecessary, but due to demographic reporting requirements, we have to ask. Thank you for understanding.

Complete all five steps for the best results. We are only a phone call away if you need any help and our team members are looking forward to helping you get to your very best healthy.

***HSNT’s sliding fee scale discount is updated annually on March 1st based on the income guidelines set by the US Department of Health and Human Services. This update may change the price you pay for the services provided. Please request more information from our medical center receptionist or ask to speak with the Business Office Manager if you have any questions. We ask that you not delay necessary medical attention for financial reasons.***

Please complete the following forms before your appointment.

Please complete this form even if you have health insurance. Doing so will allow our team to apply any discounts that might be available to you.

Please take the time to read about our practice

Thank you for taking the time to fill out the forms!

Release of Information

Authorization for Release of Information – Denton/Collin County Center

Authorization for Release of Information – Wylie Children’s Medical Clinic

Additional Patient Forms

Self Declaration of Income

Sliding Fee Discount Declination Form

Statement of No Income

Permission for Non-Parent/Guardian

Consent for Medical Treatment for Minors Receiving Contraception

Pediatric ADHD Forms

Initial ADHD

ADHD Initial Parent Form

ADHD Initial Parent Form (Español)

ADHD Initial Teacher Form

CSHQ

CSHQ (Español)

MFQ Parent Report on Child-Long

MFQ Parent Report on Child-Long (Español)

PHQ 9

PHQ 9 (Español)

Parent Contract for Management of Medications for Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD)

Follow-up ADHD

ADHD Follow-up Parent Form

ADHD Follow-up Parent Form (Español)

ADHD Follow-up Teacher Form

PHQ 9

PHQ 9 (Español)

Insurance Accepted

The following commercial insurance plans are accepted at HSNT, and we are working daily to add additional insurance carriers. Please check back often to see if yours has been added.

Blue Cross Blue Shield

United Healthcare

Aetna

Cigna

Humana

Tricare

Medicaid

Medicare

CHIP

Oscar

Ambetter

Bright Health

HSNT’s sliding fee scale discount is updated annually on March 1st based on the income guidelines set by the US Department of Health and Human Services. This update may change the price you pay for the services provided. Please request more information from our medical center receptionist or ask to speak with the Business Office Manager if you have any questions. We ask that you not delay necessary medical attention for financial reasons.

Health Information Exchange (HIE). Health Services of North Texas participates in electronic health exchanges and may share your health information as a means to improve the efficiency and effectiveness of our healthcare system. Participation is voluntary and will not affect your access to medical care. You may choose to opt-out to the electronic health information exchanges by requesting our OPT-OUT form from your provider or our staff.