Making An Appointment

Patient Rights & Responsibilities

To expedite the check-in process, please print and complete your forms in advance and bring them to your appointment.

• HS Medical History Form (New form needed every 3 years)
• Consent Form for Minors (under 18) (Parent/Guardian must sign)
• Consent Form for Minors (Emancipated Minor ONLY)
• HS Financial Policy (First visit only)
• HIPAA-Receipt Form (Sign after reading Notice of Privacy Practices)
• HIPAA-Notice of Privacy Practices-Short Version (No need to print)
• HIPAA-Notice of Privacy Practices-Long Version (No need to print)
• Advance Directives (Not required. For questions regarding the form, please contact Student Legal Services.)

Record Release Forms

If you would like a copy of your health records from UT Arlington Health Services, please choose the appropriate form from the list below, print, complete, sign and mail/fax with a copy of picture identification to UT Arlington Health Services.

Mail to:          UT Arlington Health Services
                      Box 19329
                      Arlington, TX 76019

Fax to:           817-272-3829

• HS Records Release Form (To receive records of services performed at our facility)
• HS Records Release Policy (Procedure and Cost for obtaining health records from UT Arlington Health Services