Please take a few moments to answer the questions below. Your feedback will help us to determine whether to offer our valued patients several of the country's most popular aesthetic and medical procedures.
Please Note: So that we may maintain the most up to date and accurate information on our patients, we will request that your review and update this form at least once a year.
Please contact your pharmacy for medical refills. You Pharmacy will fax us a medication refill request which the physician will review. Refill authorizations may take up to 72 hours. Please allow sufficient time for us to process your refill request.
Optional Authorization for Release of Medical Information
I authorize Female Health Associates of North Texas, PLLC to use the contact information listed below to discuss and/or disclose information regarding any matter relating to my appointments, billing information, and/or medical care. This authorization will remain in effect until I provide written notification to Female Health Associates of North Texas, PLLC os changes or update. I authorize Female Health Associates of North Texas, PLLC to use the additional contact information listed below to discuss or disclose information regarding any matters relating to my appointments, insurance, billing information, test results and/or medical care.
Please Provide a Copy of all Insurance Cards and a Driver's License / Photo ID
Medical Insurance Information
Our office, physician and staff are committed to securing the privacy of your health information. We are making available to you a copy of our Notice of privacy Practices.
Consent for Treatment, Release of information, Authorization & Assignment of Benefits
Financial and Payment Guidelines
Payment is due at time of service. this includes all co-pays, deductibles and co-insurance. If your insurance company requires a referral, it is the patient's responsibility to obtain the referral prior to your appointment.
I have read, fully understand and agree to the above consent for treatment, financial responsibility statement, payment guidelines and release of medical information and insurance authorization, and medical refill policy. I also certify that all of the information provided is complete and accurate.
Appropriate sections to be completed by patient