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Making An Appointment

You must have an appointment to be evaluated by a provider at Health Services. Appointments can be scheduled online, over the phone or in person. If you need to cancel or reschedule an appointment, please provide four hours advance notice, otherwise a no-show/missed appointment charge will be assessed to your account.

New Patient Packet (Please print packet and complete forms prior to appointment)

Forms

Medical History Form (required for first visit only) (Form 9-1A)

http://www.uta.edu/policy/form/9-1A

Financial Policy (Form 9-2)

http://www.uta.edu/policy/form/9-2

Authorization to Treat Minors (Consent by Minor to Own Treatment)  (Form 9-3)

http://www.uta.edu/policy/form/9-3

Consent for Treatment of a Minor Who Does Not Have Legal Power to Consent (Form 9-4)

http://www.uta.edu/policy/form/9-4

Notice of Privacy Practices and Acknowledgement Receipt (Form 9-5)

http://www.uta.edu/policy/form/9-5

Authorization for the Use and Disclosure of Protected Health Information (Form 9-7)

http://www.uta.edu/policy/form/9-7

Authorization for the Use and Disclosure of Protected Health Information to Outside Entity (Form 9-8)

http://www.uta.edu/policy/form/9-8

Your Rights and Responsibilities

Patient Rights and Responsibilities

Your Privacy

Health Services follows applicable State Medical Privacy Laws, including:

• Occupations Code Chapter 159

• Health & Safety Code Chapter 611

For questions regarding your medical records please contact the Administration Office at 817-272-2771.