Health Services of North Texas
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Patient Forms

Thank you for choosing Health Services of North Texas (HSNT) for your medical and wellness care. We are here to support you and your family every step of the way. You are on your way to connecting with a caring team of providers who will help you reach your best health.

Why We Ask for This Information

To provide you with the best possible care, we need some information about you, your medical history, and your health needs. Complete your forms ahead of time to help with the following:

  • Shorten your check-in time
  • Improve communication with your care team
  • Make your visit smoother and less stressful

For best results, please complete all five steps at least 24 hours before your appointment to ensure everything is ready for your visit. Some questions may seem unnecessary, but they are required for health reporting and care coordination.

Thank you for your understanding. If you need help at any time, our team is just a phone call away. We are happy to assist you and look forward to caring for you.

Want to learn more about Our Flat Rate Office Visit Fee & Sliding Fee Scale Discount?

Complete All 4 Steps

Step 1 – General Patient Information

Patient Forms

Step 2 – Patient History

Adult Medical History
Pediatric Medical History
OBGYN Medical History
Prenatal Medical History

Step 3 – Consent

Consent to Treatment
Patient Communication Consent

Step 4 – Fee Scale

Application for sliding fee scale

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.

Form Resources For You

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 Initial ADHD Forms

ADHD Initial Parent Form En Español ADHD Initial Teacher Form
CSHQ En Español MFQ Parent Report on Child-Long En Español PHQ 9 En Español Parent Contract for Management of Medications for Attention Deficit Disorder (ADD) / Attention Deficit Hyperactivity Disorder (ADHD)

Pediatric Follow-up ADHD Forms

ADHD Follow-up Parent Form En Español ADHD Follow-up Teacher Form
PHQ 9 En Español

Other Services

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
  • Group & Pension Administrators (GPA)
  • Medicaid
  • Medicare
  • CHIP
  • Healthy Texas Women
  • Ambetter
  • Wellpoint
  • Superior

HSNT updates its sliding fee scale every year based on U.S. Department of Health and Human Services income guidelines. This may change the cost of your care. For details, please speak with our receptionist or the Business Office Manager. Please do not delay needed medical care due to financial concerns.

Health Services of North Texas participates in electronic health information exchanges to improve care coordination. Participation is voluntary and does not affect your access to care. You may opt out at any time by requesting an opt-out form from your provider or staff.

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