Person responsible for payment
I give authorization to the following person(s) to discuss my medical care, appointments, and billing account information with any staff member of Health Services of North Texas. You may use the same person listed as your emergency contact.
For children under the age of 3
I authorize this Release to be kept on file at the clinic and that it can be cancelled, revoked or have changes in authorized person(s) at any time by my written request.
Please type in your full name