Downloadable Forms Print E-mail

Below are the forms that are available for download:

Forms
Description
Authorization Form
Standard Form for patient health information disclosure.
Demographic Form Patient registration information
Patient History Form
Patient Medical History
Privacy Notice Form
Standard Privacy Notice

Submissions:

  1. Email:
    To submit the forms online, please complete the forms accordingly and email them to: This e-mail address is being protected from spambots. You need JavaScript enabled to view it
  2. Fax:
    To Fax the forms, you will need to complete the form and fax it to: 713-796-9302.
  3. Print:
    You can also complete the form, print it, and bring it with you during your next visit to the center.
 
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