New Adult Patient History Intake

Please correct the errors described below.

To our new patients: Welcome to the NW Cypress Pediatrics and Family Medicine, PLLC. To help us establish you with our practice, please provide us with your complete health history: body, mind and spirit.

Personal History


Add allergy


(rank in terms of importance to you)

Add problem/reason

Current Medications

Add current medication

Current Herbs/Vitamins/Supplements

Add current herb/vitamin/supplement


(list prior illness, injury, hospitalizations)

Add medical/surgical/trauma history



(list sex/ages if applicable)

Add child



Add travel history




List the dates of our most recent test or vaccination.

Others: Recent Radiographic Procedures:

(Xray, MRI, CT Scan, Ultrasound, Bone Scan, Pet Scan, etc): Please include reason and date:

Add radiographic procedure


(List 3 contacts)

Add emergency contact

This history record has been designed to facilitate our patients continuity of care at NW Cypress Pediatrics and Family Medicine, PLLC. This is a confidential record and will be kept in this facility. Information contained here will not be released to anyone without your authorization to do so.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Thank you for choosing NW Cypress Pediatrics and Family Medicine. We realize you have a choice in selecting healthcare and we are honored you have chosen us. Our staff is committed to providing our patients with the highest quality of care possible. In doing so, we would like to provide you with information regarding our office policies


Our providers participate with many health plans and as a courtesy to our patients, we file claims with these companies. It is ultimately your responsibility for the full and timely payment of your account.

Check In

Please be prepared to submit the following documents when checking in for each visit. These documents will be scanned and saved as part of your patient record.

  • Current Insurance Card. Make sure your PCP is an NW Cypress Pediatrics and Family Medicine provider.
  • Current Photo Identification
  • Update to contact information such as home address, phone numbers, contact information, email address, employer information, etc.
  • Current Immunization records (for new patients and check ups)
  • Necessary documents for the visit (ex hospital discharge summary, urgent care paperwork, labwork results, guardianship papers, etc)

Verification of Benefits

We will attempt to verify coverage and benefits prior to your visit. If we are unable to obtain a verification of coverage, you may be asked to pay in full or reschedule your visit for a time the verification can be obtained. This verification will be used to estimate your financial responsibility; however, this verification is not a guarantee by your health plan to pay for services received.

Payment of Patient Responsibility

Payment of your estimated patient responsibility is expected at the time services are rendered. This payment will include known deductibles, copays, and coinsurance amounts applicable for each visit and or procedure. While we may estimate your financial responsibility, it is your insurance company that makes the final determination regarding eligibility and benefits. For your convenience we accept cash, checks, most major credit cards and debit cards. You will be responsible for payments not received by your insurance

NSF Checks/Denied Credit Card Payments

You will be charged a $25.00 fee should a payment be returned for insufficient funds. This fee applies to payments made at our front desk, mailed in to the Business Office, electronically via the internet, or payments by phone.

Past Due Amounts

In the event your account becomes past due, and all efforts to collect payment have failed, your account may be referred to a collection agency.

Additional Services Identified During Treatment

Please be aware additional charges may be incurred if during the course of a physical exam a physician addresses, diagnoses, or treats problem-focused health concerns unknown at time of check in.

Non Covered Services

Please be aware certain office procedures or services may not be covered, or may be considered “not medically necessary”, “experimental”, “cosmetic”, or simply “non-covered” by your health plan. You are responsible for payment of these services. In the event your care exceeds a plan limitation, you will be responsible for the balance. It is your responsibility to know the benefits and limitations of your current health care coverage. This clinic will provide medically necessary care based on patient’s needs, not a patient’s insurance coverage. This clinic is not responsible for knowing your plant’s specific benefit and coverage limitations.

Third Parties Insurance

We do not file insurance claims to non-contracted third parties involving automobile accidents, accidental injury, property insurance, etc. You will need to pay in full at the Time of Service and file the claim with your insurance company. An itemized statement may be obtained by calling our business office. This statement will assist you with reimbursement. It is your responsibility to file claims in these instances.

Appointment Scheduling

Please be advised, as a courtesy, an automated service will call the primary phone number and email listed on file to remind you of your appointment date and time. You must notify the office within 24 hours of your scheduled appointment if you are unable to keep your appointment. Failure to notify the office within 24 hours may result in a $25.00 assessment to your account. Repeated failure to call and cancel your scheduled appointment without the proper 24 hour notice may result in your dismissal as a patient. Please notify the office immediately for any changes to how your would like to be contacted.

Forms/Medical Letters

We are happy to assist you by completing forms and generating medical letters for you upon your request. The fee for this service varies depending on the form or letter, but most do not exceed $25.00 per form. Payment is collected when you pick up the documents. Please allow 10 business days.

Medical Records

Requests for your medical records must be in writing via a special release form. Release of records is managed via an outside vendor. The cost is $25.00 for the 1st 20 pages and $.50 for each additional page. You will pay the outside vendor for these copies.

Office Hours

While appointment times vary for each provider, our office staff is available by telephone during regular business hours. Because our providers and nurses are often tending to patients, it is typically necessary for you to leave a message. So we may assist you in a timely manner, please leave pertinent information to include the reason for your call and best number to call. We have an answering service to take your calls before and after our scheduled office hours.

  • Emergency Needs – always call 911
  • Prescription Refills – call during regular office hours and if leaving a message, provide your name, the medication, your pharmacy name, location, and phone number. Refills of controlled substances and/or narcotics MUST be filled by speaking with a medical staff member. You might need to schedule an appointement for refills depending on the nature of the refill.
  • After Hours- please call 281-469-7400 to schedule telemedicine visit.

Authorization to Release Information

I hereby authorize NW Cypress Pediatrics and Family Medicine to: (1) release any information necessary to insurance carriers regarding my illness and treatments; (2) process insurance claims generated in the course of an examination or treatment; and (3) allow a photocopy of my signature to be used to process insurance claims for the period of a lifetime. This order will remain in effect until revoked in writing.

Assignment of Benefits

I hereby assign all medical benefits to include major medical benefits to which I am entitled. I hereby authorize and direct insurance carrier(s), include Medicare, Medicaid, private insurance and any other health/medical plan, to issue payment check(s) directly to NW Cypress Pediatrics and Family Medicine for medical services rendered to myself and/or my dependents regardless of my insurance benefits, if any. I understand that I am responsible for any amount not covered by insurance.

Financial Responsibility

I acknowledge I have requested medical services from NW Cypress Pediatrics and Family Medicine, on behalf of myself and/or my dependents and understand that by making this request I become fully financially responsible for any and all charges incurred in the course of the treatment authorized.

I agree to pay NW Cypress Pediatrics and Family Medicine for all services and products administered. I understand and acknowledge that any monies collected prior to the date services are rendered or products are administered will be applied as a deposit towards total charges assessed for the services rendered. The deposit shall not be considered payment in full. If I participate in a managed care plan, such as an HMO or PPO, I promise to pay for any services or products administered that are not covered under the plan as a result of inaccurate, incomplete or untimely patient information provided by me to the clinic and for any out-of-network charges.

For telemedicine services, a $50 charge will be made at the time of scheduling. We will file a claim with your insurance. If your insurance covers the visit, the balance will be credited to your account. If your insurance does not cover the visit, the $50 will pay for the telemedicine visit.

I further understand that fees are due and payable on the date the services are rendered and agree to pay all such charges incurred in full immediately upon presentation of the appropriate statement. A photocopy of this assignment is to be considered as valid as the original.

My signature certifies I have read and understand the above content of this document.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.


Thank you for choosing NW Cypress Pediatrics and Family Medicine, PLLC. We are committed to providing you with quality and affordable health care and we are pleased to discuss our professional fees with you at any time. Your clear understanding of our financial policy is important to our professional relationship. Please ask if you have any questions about this financial policy.

  1. Co-payments and deductibles. All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your co-payment at each visit.
  2. Non-covered services. Please be aware that some – and perhaps all of the services you receive may be non-covered or not considered reasonable and necessary by Medicaid or other insurers. You must pay for these services in full at the time of visit.
  3. Proof of insurance. All patients must complete our patient information form before seeing the doctor. We must obtain a copy of your current valid insurance to provide proof of insurance at each visit. Often this verification requires us to share the reason for your visit with your managed care plan.
  4. Proof of insurance. All patients must complete our patient information form before seeing the doctor. We must obtain a copy of your current valid insurance to provide proof of insurance at each visit. Often this verification requires us to share the reason for your visit with your managed care plan.
  5. Coverage changes. If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. If your insurance company does not pay your claim in 45 days, the balance will automatically be billed to you.


Minor must have an authorization for medical treatment signed by his/her parent/guardian and is responsible for providing current insurance information for self. Please note that co-payments and/or deductibles are expected at the time of service.


We do not get involved in disputes between divorced parents regarding financial responsibility for their child’s medical expenses. By signing as guarantor below, you agree to be financially responsible for the care we provide to your child, regardless of whether a divorce decree or other arrangement places that obligation on your former spouse.


Indemnity/Fee for Service: We require full payment at the time of service. We will supply you with a copy of your itemized statement so that you can file for reimbursement from your insurance company. Should your insurance company require a more detailed description of services, please have them request it in writing. Insurance is a contract between you and your company. We are not a party to your contract. We will not become involved in disputes between you and your insurance. You are responsible for timely payment of your account.


  • Each time you make an appointment with us, it is your responsibility to make sure the patient is currently under contract with your managed care plan.
  • Verification of your coverage and benefits may be required. Often this verification requires us to share the reason for your visit with your managed care plan.
  • I have read and understood that I am personally responsible for payment on this account.

Assignment: I hereby authorize payment directly to NW Cypress Pediatrics and Family Medicine, PLLC. Any changes in this authorization must be received in writing within 30 days of the effective date.

I understand that this practice has a no show appointment fee of $25 dollars. I am responsible for paying the fee if I do not cancel an appointment with 24 hours notice.

In the event my insurance company deems a service to be “non-covered” I understand that I am personally responsible for payment. I agree to the release of any and all medical information, including HIV test results, and financial information necessary to process this and any future claims to my insurer or payer of health benefits, as I may designate that person or entity from time to time, for an indefinite period or until I submit a written revocation of this release. Any changes to this authorization must be received in writing within 30 days of effective date.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.


The Federal Health Insurance Portability and Accountability Act (HIPAA) laws arc written to protect the confidentiality of your Health Information. The following notice details the policies and procedures that are used to ensure that your Health Information is not shared with anyone who does not require it. It also describes your rights to access and control your Health Information. ''Health Information" is information about you, including demographic information, that may identifY you and that relates to your past, present or future physical or mental health condition and related health services

We will use and communicate your Health Information only for the purposes of providing treatment, obtaining payment and conducting health care operations. Your Health Information will not be used for other purposes unless we have asked for and been voluntarily given your written permission.

How your Health Information may be used:

To Provide Treatment

We will use your Health Information within our office to provide you with the best health care possible. This may include administrative and clinical office procedures designed to optimize scheduling and coordination of care between your provider, nurses, medical technicians and business office staff. In addition we may share your Health Information with other providers, referring providers, clinical and imaging laboratories, pharmacies or other health care personnel providing you treatment.

To Obtain Payment

Your Health Information may be used with an invoice to collect payment for treatment that you receive in our office. We may do this with insurance forms filed for you in the mail or sent electronically. We will only work with companies with a similar commitment to the security of your Health Information.

To Conduct Health Care Operations

We may use or disclose, as needed, your Health Information in order to support the business activities of this practice. These activities include, but are not limited to, quality assessment activities, employee performance evaluations, training for medical students, licensing, and conducting or arranging for other business activities. We may use a sign-in sheet at the registration desk for you to write your name and indicate the nature of your visit. We may call your name in the waiting room when your provider is ready to see you. We may use or disclose your Health Information, as necessary, to contact you to remind you of your appointment.

Disclosure of Your Health Information

We may use or disclose your Health Information in the following situations without your authorization. These situations include:

  • Abuse, neglect, or domestic violence - Government authorities will be notified only when we are compelled by our ethical judgment when we believe we are specifically required or authorized by law, or with your agreement.
  • Public health and national security - Federal officials or military authorities may require your Health Information to complete an investigation related to public health or to national security. Health Information could be important when the government believes that the public safety could benefit when the information could lead to the control or prevention of an epidemic or the understanding of new side effects of a drug treatment or medical device.
  • For Law Enforcement - As permitted or required by State or Federal law, we may disclose your health information to a law enforcement official for certain law enforcement purposes, including, under certain limiting circumstances, if you are a victim of a crime or in order to report a crime.
  • Family, Friends and Caregivers - With your permission, we may share your health information with those you tell us will be helping you with your home hygiene, treatment, medications, or payment. In an emergency when you are unable to tell us what you want, we will use our best judgment when sharing your Health Information only when it will be important to those participating in providing your care.

Other than stated above, or where Federal, State, or Local law requires us, we will not disclose your Health Information other than with your written authorization. You may revoke that authorization at any time, except to the extent that your provider or the provider's practice has taken an action on the use or disclosure indicated in the authorization.

Your Rights

The following is a statement of your rights with respect to your Health Information:

  • Restrictions - You have the right to request a restriction of your Health Information. Your request must state the specific part of your Health Information to be restricted and to whom you want the restriction to apply. Your provider is not required to agree to a restriction that you may request, particularly if your provider believes that it is in your best interest to permit use and disclosure of your Health Information.
  • Confidential Communications - You have the right to request to receive confidential communication from us by alternative means or at an alternative location; for example, through sealed mail, or with no family members present. We will make every effort to honor your reasonable requests for confidential communications.
  • Inspect and Copy Your Health Information - You have the right to inspect and copy your Health Information, including your complete chart, imaging records and billing records. Under Federal law, however, you may not inspect or copy the following records; psychotherapy notes, information compiled in reasonable anticipation, or use in, a civil, criminal, or administrative action or proceeding, and Health Information that is subject to law that prohibits access to Health Information. Let us know if you would like a copy of your Health Information. There may be a reasonable fee to duplicate and assemble your copy.
  • Amend Your Health Information - You have the right to ask us to amend your records if you believe your Health Information records are incorrect or incomplete. We will be happy to accommodate you as long as our office created and maintains this information. Please provide your request in writing and describe your reason for the change. If we deny your request, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.
  • Documentation of Health Information - You have the right to ask us for a description of how and where your Health Information was used by our office for any reason other than for treatment, payment or health operations. Please let us know in writing the period for which you are interested. There may be a reasonable fee for your request.
  • Request a Paper Copy of this Notice - You have the right to obtain a copy of this notice of Health Information Privacy Practices.

We are required to practice the policies and procedures described in this notice but we do reserve the right to change the terms of the notice and will inform you by mail of any changes.

You have the right to complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been compromised. Please let us know of your concerns or complaints in writing. We will not retaliate against you for filing a complaint.

Patient Acknowledgment

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Written Acknowledgment of Receipt of NW Cypress Pediatrics and Family Medicine, PLLC


General Consent to Treat


This Facility has on staff an advanced practice nurse of assist in the delivery of medical care. An advanced practice is not a doctor. An advanced practice nurse is a registered nurse who has received advanced education and training in the provision of health care. An advanced practice nurse can diagnose, treat, and monitor common acute and chronic diseases as well as provide health maintenance care. In Addition, the advanced practice nurse may treat minor lacerations and other minor injuries.

I have read the above, and hereby consent to the services of an advanced practice nurse for my health care needs.

I understand that at any time I can refuse to see the advanced practice nurse and request to see a physician if a physician is available.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Electronic Medical Records and Electronic Prescriptions

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Telemedicine Consent Form

Telemedicine services involve the use of secure interactive videoconferencing equipment and devices that enable health care providers to deliver health care services to patients when located at different sites.

1. Nature of telemedicine services. During the telemedicine consultation:

  • This is a live 2 way audio and video involving the use of electronic communications to enable health care providers to continue to provide medical care
  • Details of your medical history, examinations, lab, diagnostic results and any other necessary medical problems may be discussed as in a regular visit

2. Expected Benefits:

  • Improved access to medical care by enabling patient to remain at his/her remote site while
  • Avoid urgent cares and emergency room if not needed
  • Access health care 24 hours a day, 7 days a week.

1. I understand that the same standard of care applies to a telemedicine visit as applies to an in-person visit.

2. I understand that I will not be physically in the same room as my health care provider. I will be notified of and my consent obtained for anyone other than my healthcare provider present in the room.

3. I understand that there are potential risks to using technology, including service interruptions, interception, and technical difficulties.

  • If it is determined that the videoconferencing equipment and/or connection is not adequate, I understand that my health care provider or I may discontinue the telemedicine visit and make other arrangements to continue the visit.

4. I understand that I have the right to refuse to participate or decide to stop participating in a telemedicine visit, and that my refusal will be documented in my medical record. I also understand that my refusal will not affect my right to future care or treatment.

  • I may revoke my right at any time by contacting NW Cypress Pediatrics and Family Medicine at 281-469-7400.

5. I understand that the laws that protect privacy and the confidentiality of health care information apply to telemedicine services.

6. I understand that my health care information may be shared with other individuals for scheduling and billing purposes.

  • I understand that my insurance carrier will have access to my medical records for quality review/audit.
  • I understand that I will be responsible for any out-of-pocket costs such as copayments or coinsurances that apply to my telemedicine visit.
  • I understand that health plan payment policies for telemedicine visits may be different from policies for in-person visits.

7. I understand that this document will become a part of my medical record.

By signing this form, I attest that I (1) have personally read this form (or had it explained to me) and fully understand and agree to its contents; (2) have had my questions answered to my satisfaction, and the risks, benefits, and alternatives to telemedicine visits shared with me in a language 1 understand; and (3) am located in the state of Texas and will be in Texas during my telemedicine visit(s).

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.