Patient Forms

Thank you for choosing Health Services of North Texas for your medical and wellness needs. We accept Medicare, Medicaid, CHIP and most Major Medical Insurance and offer a sliding fee scale to those patients who qualify.

We want your first visit to be a positive experience! Please take the time to complete your patient paperwork 24 hours before your scheduled appointment. You will love the results!

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… 940-381-1501.

Our staff is looking forward to serving you!

Please print and fill out the forms below before your appointment.

Authorization for Release of Information – Denton/Collin County Center
Authorization for Release of Information – Plano/Wylie Children’s Medical Clinic
Patient Information Form

step 1 buttonarrowpatient formformas paciente
                                                                                pediatric form spanish
                                                                                pediatric form spanish
step 2 buttonarrowAdult Medical History Buttonadult-medical-history-spanish
step3buttonarrowpatient informationpatient information - spanish
step 4arrowconsent to treatmentconsent to treatment spanish
step 5arrowsliding scale feesliding-fee-scale-spanish

step 5arrowprescription history consent formConsentimiento De Historial De Medicamentos

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

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 Health Care
Denton County Indigent
Group and Pension Administrators (GPA)

*Medicare cards are changing! See what is changing and what the new cards look like here.

HSNT’s sliding fee scale discount is updated annually on April 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 a Patient Service Coordinator 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 health care 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.