Patient Forms Forms for new patients, financial assistance, privacy practices, and medical records are available to download in English and Spanish. Forms in English Forms in Spanish Forms in English Registration Texas Vaccines for Children Patient Eligibility Screening Record New Patient Forms for Women - English Financial Assistance Financial Assistance Program Requirements (English & Spanish) Statement of Self-Employment Income (English) Statement of Support (English) Wage Verification (English and Spanish) Privacy Notice of Privacy Practices (English) Medical Records Request to Inspect Form (English) Request Amendment to PHI Form (English) Confidential Communications Request Form (English) Restriction Request Form (English) HIPAA Privacy Complaint Form (English) Authorization to Disclose PHI Form (English) Request for an Account of Disclosures Form (English) After-Hours Medical Attention for Children Medical Attention — Evenings and Weekends (English & Spanish) Forms in Spanish Registration Texas Vaccines for Children Patient Eligibility Screening Record (Spanish) New Patient Forms for Women - Spanish Financial Assistance Financial Assistance Program Requirements (English & Spanish) Statement of Self-Employment Income (Spanish) Statement of Support (Spanish) Wage Verification (English and Spanish) Privacy Notice of Privacy Practices (Spanish) Medical Records Request to Inspect Form (Spanish) Request Amendment to PHI Form (Spanish) Confidential Communications Request Form (Spanish) Restriction Request Form (Spanish) HIPAA Privacy Complaint Form (Spanish) Authorization to Disclose PHI Form (Spanish) Request for an Account of Disclosures Form (Spanish) After-Hours Medical Attention for Children Medical Attention — Evenings and Weekends (English & Spanish)
