If you are a new patient or have not seen our physicians in the last three years, please take a few minutes to complete this New Patient Forms (Main Office) or New Patient Forms (Pearland Office) prior to your appointment.

Please fax the completed forms to our office at (713)795-5254 prior to your appointment and always bring the original copy on your appointment date.

It is required by the Federal Trade Commission (FTC) that you must present your picture ID (e.g. driver license) and insurance card(s) for your office visit. We suggest patients NOT to mail the completed forms to our office in order to avoid any delays handling in the post office.

Effective July 1, 2009, we will move our Pearland Satellite Cliniic to:

Medical Place 1
10905 Memorial Hermann Drive
Suite 113
Pearland, TX 77584

If you have Medicare and other insurance, please see Appendix A to determine whether Medicare is primary or secondary.

Please click the following icon for a free download of Adobe Reader in order to open the above New Patient Forms.

My Medical Portfolio (NEW!!)

Patient who registers with the practice can access My Medical Portfolio and links through a portal established by our practice. You can register by clicking the above link to request new account to request information.

 

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Privacy Notice

We are committed to treating and using our patient's protected health information responsibly. Under the federal Health Insurance Portability and Accountability Act (HIPAA), we have developed this Privacy Notice for patients to understand how this information may be used and disclosed.

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• The physicians will bill insurance plans as a courtesy to their patients if the patient provides the required insurance information before the filing deadline and signs an assignment of benefits statement. All information given regarding the ability to pay, third party insurance, employment, etc., will be subject to verification.
• It is the patient's responsibility to determine whether a referral is required and referral can be requested from your primary care physician. If we have not received an authorization prior toyour arrival at the office, we have a telephone available for you to call your primary care physician to obtain it. If you are unable to obtain the referral at that time, you will be rescheduled.
• If the patient's insurance rejects, denies or covers only a portion of treatment, the patient shall be responsible for immediate payment for the medical service provided. This payment may be requested and is due at the time of service. A pre-treatment deposit may be required.

• Prior to providing services, payment of prior outstanding accounts will be requested and should be received. Patients with unpaid delinquent accounts or accounts which have been written off to bad debt may be denied treatment if not medically urgent.
• Accounts which cannot be collected by the physician after normal in-house collection procedures may be referred to a collection agency, magistrate, or attorney for further collection action in accordance with the physician's established guidelines. Changes shown by statements are agreed to be correct and reasonable unless protested in writing within (30) thirty days of billing.

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