Insurance & Forms

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Patient Forms

01

Records Release

Patient medical release of records form.

02

Registration

Patient registration, insurance, and records release form.

03

Notice of Privacy

The Notice of Privacy Practices form describes how patient medical information is used and disclosed and how you, the patient, can have access to this information.

04

Patient Authorization

The General Patient Authorization form describes our practice policies and payment policies and procedures. It also outlines policies regarding release of patient information.

05

Minor Consent

The Minor Consent to Treat form allows the providers in our office to see and treat your child when a parent in not present. All surgical procedures do, however, do require a parent being present.

Medical Insurance

We accept the following providers:

  • AARP Secure Horizon Complete
  • Aetna Commercial
  • Aetna Medicare PPO & HMO
  • BCBS TX Essentials HMO
  • BCBS TX Medicare PPO
  • BCBS TX PPO/POS
  • BCBS TX Premier HMO
  • Blue Advantage HMO Exchange
  • Care N’ Care
  • Cigna
  • Coventry
  • First Health
  • Galaxy Health Network
  • HealthSmart Accel
  • HealthSmart GEPO
  • HealthSmart PPO
  • Humana Advantage Plus
  • Humana Choice Care
  • Humana Medicare HMO
  • Humana Medicare PPO/PFFS
  • IMS PPO
  • SmartCare/Imagine Health PPO
  • UHC Medicare Adv
  • United Healthcare

Request an Appointment

Use our convenient online form to request an appointment at our Fort Worth office. You can also schedule via phone, at 817-820-0011.

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