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New Patient Demographics and Contact Information

Please select the name of your physician. If you are not sure who your primary care physician is, please click one of the links below to view a list of our physicians and locations.
Patient Name*
Date of Birth*
MM/DD/YYYY
Date of Birth (Immtrac)
Ethnicity*
Address*
Preferred Language*
Use your mouse or finger to draw your signature above

Parental Information

Is the patient a child?*
Mother's Name
Mother's Date of Birth
Father's Name
Father's Date of Birth

Marital Status

Marital Status*
Spouse's Name
Spouse's Date of Birth

Employer Information

Patient Employment*

Pharmacy Information

Pharmacy Address

Emergency Contact

Would you like to add an emergency contact?*
Emergency Contact's Name *
Emergency Contact's Address

Insurance Information

Do you have Insurance?*
Insurance Claims Address
Patient's Relationship to the Policy Holder *
Policy Holder's Name*
Policy Holder's Date of Birth*
MM/DD/YYYY
Policy Holder's Address
Do You Have Other Insurance?*

I consent and authorize HealthTexas Medical Group of San Antonio to release all information contained in my financial and medical records to my insurance company or health plan, or any other person or entity that is responsible for paying or processing for payment any portion of my bill. I understand that I am totally responsible for payment of all fees and services rendered, regardless of insurance coverage or other responsibilities, and ultimately responsible for payment in full if my insurance company does not pay in a timely manner. I also understand that my prescription history from non-HTMG providers and pharmacies will be available to HTMG. I permit a copy of this authorization to be used in place of the original.


HIPAA Authorization Release

Would you like to add an individual who can have access to and receive your health information?*
(Ex: Family member, friend, or representative who will be participating in your care)

Please read this entire form before signing and complete all the sections that apply to your decisions relating to the disclosure of protected health information.  Covered entities as that term is defined by HIPAA and Texas Health & Safety Code § 181.001 must obtain a signed authorization from the individual or the individual’s legally authorized representative to electronically disclose that individual’s protected health information.  Authorization is not required for disclosures related to treatment, payment, health care operations, performing certain insurance functions, or as may be otherwise authorized by law.  Covered entities may use this form or any other form that complies with HIPAA, the Texas Medical Privacy Act, and other applicable laws. Individuals cannot be denied treatment based on a failure to sign this authorization form, and a refusal to sign this form will not affect the payment, enrollment, or eligibility for benefits. 

I AUTHORIZE THE FOLLOWING TO DISCLOSE THE INDIVIDUAL’S PROTECTED HEALTH INFORMATION:

HealthTexas Medical Group (Administrative Office)

2961 Mossrock

San Antonio, Texas 78230

Phone 210-731-4800   Fax 210-731-4810

Individual 1*
Individual 1 Date of Birth
Would you like to add a second individual?*
Individual 2*
Individual 2 Date of Birth
Start - Period of Healthcare of information to be released from*
Defaults to today's date
End - Period of Healthcare of information to be released to*
The default time period is ten years
REASON FOR DISCLOSURE*
Other Reasons for Disclosure*
(Choose only one option below)
WHAT INFORMATION CAN BE DISCLOSED?*
Complete the following by indicating those items that you want disclosed. The signature of a minor patient is required for the release of some of these items. If all health information is to be released, then check only the first box.
Other Information to be Disclosed*
Check any that apply. If checking all, please select "All Health Information" in the preceding question
Please provide a brief description

Your initials are required to release the following information:

Please initial here to allow release or type DECLINE
Please initial here to allow release or type DECLINE
Please initial here to allow release or type DECLINE
Please initial here to allow release or type DECLINE

RIGHT TO REVOKE:  I understand that I can withdraw my permission at any time by giving written notice stating my intent to revoke this authorization to the person or organization named under “WHO CAN RECEIVE AND USE THE HEALTH INFORMATION.”  I understand that prior actions taken in reliance on this authorization by entities that had permission to access my health information will not be affected. 

SIGNATURE AUTHORIZATION:  I have read this form and agree to the uses and disclosures of the information as described.  I understand that refusing to sign this form does not stop disclosure of health information that has occurred prior to revocation or that is otherwise permitted by law without my specific authorization or permission, including disclosures to covered entities as provided by Texas Health & Safety Code § 181.154(c) and/or 45 CFR § 164.502(a)(1).  I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state privacy laws.


Signature of Individual or Individual’s Legally Authorized Representative.

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If representative, specify relations to the individual:

Signature of Minor Individual (if applicable)

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MinDayFFPR

HIPAA Authorization Request

Do you have a previous PCP that you would like for us to request your medical records from ?*

Please read this entire form before signing and complete all the sections that apply to your decisions relating to the disclosure of protected health information.  Covered entities as that term is defined by HIPAA and Texas Health & Safety Code § 181.001 must obtain a signed authorization from the individual or the individual’s legally authorized representative to electronically disclose that individual’s protected health information.  Authorization is not required for disclosures related to treatment, payment, health care operations, performing certain insurance functions, or as may be otherwise authorized by law.  Covered entities may use this form or any other form that complies with HIPAA, the Texas Medical Privacy Act, and other applicable laws. Individuals cannot be denied treatment based on a failure to sign this authorization form, and a refusal to sign this form will not affect the payment, enrollment, or eligibility for benefits. 

I AUTHORIZE THE FOLLOWING TO DISCLOSE THE INDIVIDUAL’S PROTECTED HEALTH INFORMATION:

Previous Primary Care Physician*
Previous Primary Physician Address
Please add any names that you may be listed under with this PCP (eg: Maiden name)

WHO CAN RECEIVE AND USE THE HEALTH INFORMATION?

HealthTexas Medical Group (Administrative Office)

2961 Mossrock

San Antonio, Texas 78230

Phone 210-731-4800 Fax 210-731-4810

Start - Period of Healthcare of information to be released from*
End - Period of Healthcare of information to be released to*
The default time period is ten years
REASON FOR DISCLOSURE*
Other Reasons for Disclosure*
(Choose only one option below)
WHAT INFORMATION CAN BE DISCLOSED?*
Complete the following by indicating those items that you want disclosed. The signature of a minor patient is required for the release of some of these items. If all health information is to be released, then check only the first box.2
Other Information to be Disclosed*
Check any that apply. If checking all, please select "All Health Information" in the preceding question
Please provide a brief description

Your initials are required to release the following information:

Please initial here to allow release or type DECLINE
Please initial here to allow release or type DECLINE
Please initial here to allow release or type DECLINE
Please initial here to allow release or type DECLINE

RIGHT TO REVOKE:  I understand that I can withdraw my permission at any time by giving written notice stating my intent to revoke this authorization to the person or organization named under “WHO CAN RECEIVE AND USE THE HEALTH INFORMATION.”  I understand that prior actions taken in reliance on this authorization by entities that had permission to access my health information will not be affected. 

SIGNATURE AUTHORIZATION:  I have read this form and agree to the uses and disclosures of the information as described.  I understand that refusing to sign this form does not stop disclosure of health information that has occurred prior to revocation or that is otherwise permitted by law without my specific authorization or permission, including disclosures to covered entities as provided by Texas Health & Safety Code § 181.154(c) and/or 45 CFR § 164.502(a)(1).  I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state privacy laws.


Signature of Individual or Individual’s Legally Authorized Representative

Use your mouse or finger to draw your signature above
If representative, specify relations to the individual:

Signature of Minor Individual (if applicable)

Use your mouse or finger to draw your signature above
Minday1021

Texas Immunization Registry

The Texas Immunization Registry (ImmTrac2) is a free service of the Texas Department of State Health Services (DSHS). The Texas Immunization Registry is a secure and confidential service that consolidates and stores your immunization records. With your consent, your immunization information will be included in the Texas Immunization Registry. Doctors, public health departments, schools, and other authorized professionals can access your child’s immunization history to ensure that important vaccines are not missed. For more information, see Texas Health and Safety Code Sec. 161.007 (d). https://statutes.capitol.texas.gov/Docs/HS/htm/HS.161.htm#161.007.


Would you like to register with the Texas Immunization Registry? *
Gender*

Consent for Registration and Release of Immunization Records to Authorized Persons / Entities

I understand that, by granting the consent below, I am authorizing release of my immunization information to DSHS and I further understand that DSHS will include this information in the Texas Immunization Registry. Once in the Texas Immunization Registry, my immunization information may by law be accessed by: a Texas physician, or other health-care provider legally authorized to administer vaccines, for treatment of the individual as a patient; a Texas school in which the individual is enrolled; a Texas public health district or local health department, for public health purposes within their areas of jurisdiction; a state agency having legal custody of the individual; a payor, currently authorized by the Texas Department of Insurance to operate in Texas for immunization records relating to the specific individual covered under the payor’s policy. I understand that I may withdraw this consent at any time by submitting a completed Withdrawal of Consent Form in writing to the Texas Department of State Health Services, Texas Immunization Registry.


State law permits the inclusion of immunization records for First Responders and their immediate family members in the Texas Immunization Registry. A “First Responder” is defined as a public safety employee or volunteer whose duties include responding rapidly to an emergency. An “immediate family member” is defined as a parent, spouse, child, or sibling who resides in the same household as the First Responder. For more information, see Texas Health and Safety Code Sec. 161.00705. https://statutes.capitol.texas.gov/Docs/HS/htm/HS.161.htm#161.00705.


Please mark the appropriate box to indicate whether you are a First Responder or an Immediate Family Member.

By my signature below, I GRANT consent for registration. I wish to INCLUDE my information in the Texas Immunization Registry.

Individual (or individual’s legally authorized representative):


Use your mouse or finger to draw your signature above

Privacy Notification: With few exceptions, you have the right to request and be informed about information that the State of Texas collects about you. You are entitled to receive and review the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect. See http://www.dshs.texas.gov for more information on Privacy Notification. (Reference: Government Code, Section 552.021, 552.023, 559.003, and 559.004)


Confidential Health Questionnaire

Please mark any of the following illnesses and medical problems you have or have had and indicate the year when each started.

Illness
Previous Primary Physician
Previous Primary Physician Address

Reproductive Problems

*
Male Reproductive Problems*

Female Cancer Screening and Routine Health Maintenance

Colon Cancer Screening (MEN and WOMEN)

Type NA if you have never done these tests
Have you previously completed any of the following colon cancer screening exams? *
Date of last stool card exam *
Date of last colonoscopy*

Specialist Information

Are you Currently seeing any specialist?*
Would you like to add a second specialist? *
Would you like to add a third specialist?*

Vaccines

Please list the year received or N/A if never received 

Year
Year
Year
Year
Have You received your Covid Vaccine?*
Date Received
Date Received
Have you received your booster?
Date Received

Hospitalization

Have you ever been hospitalized? *
Hospital and City of Operation, Illness, or Injury listed above
Year of Operation, Illness, or Injury listed above
Would you like to add a second hospitalization?*
Hospital and City of Operation, Illness, or Injury listed above
Year of Operation, Illness, or Injury listed above
Would you like to add a third hospitalization? *
Hospital and City of Operation, Illness, or Injury listed above
Year of Operation, Illness, or Injury listed above
Would you like to add a fourth hospitalization?
Hospital and City of Operation, Illness, or Injury listed above
Year of Operation, Illness, or Injury listed above

Prescription Medications

Are you currently taking any prescription medications? *
Would you like to add additional prescription medication?*

Non-Prescription Medications or Supplements

Are you currently taking any non-prescribed medications and/or supplements?*

Allergies

Do you have any known allergies?*

Tobacco and Alcohol Use

Do you currently use tobacco products or have you in the past?*
Which form of tobacco products have you used currently or in the past?*
Do you drink alcohol?*

Sexual Orientation and Gender Identity

Are you sexually active?*
Do you have sex with:
Do you think of yourself as: *
What is your current gender Identity? *
What sex were you assigned at birth on your original birth certificate?*

Family Health History

Is your father living?
Please check the box if your Father has/had any of the following:
Is your mother living?
Please check the box if your Mother has/had any of the following:
Do you have any siblings?
Please check the box if any of your siblings have/had any of the following:
Do you have any siblings who have passed away?
Please check the box if your spouse has/had any of the following:
Do you have children?
Have any of your children passed away?
Please check the box if any of your children have/had any of the following:
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Advanced Directive/Medical Power of Attorney

Do you have an advance directive or living will?*
Do you have a Medical Power of Attorney?*

Cancellation and No Show Policy

We understand that situations arise in which you must cancel your appointment. It is therefore requested that if you must cancel your appointment you provide more than 24 hours notice. This will enable another person who is waiting for an appointment to be scheduled in that appointment slot. With cancellations made less than 24 hours notice, we are unable to offer that slot to other people. 

Office appointments which are cancelled with less than 24 hours notification may be subject to a $25.00 cancellation fee. 

Patients who do not show up for their appointment without a call to cancel an office appointment are considered a NO SHOW. Patients who No-Show three (3) or more times may be dismissed from the practice, thus they will be denied any future appointments. The Cancellation and No Show fees are the sole responsibility of the patient and must be paid in full before the patient’s next appointment. 

We understand that special, unavoidable circumstances may cause you to cancel within 24 hours. Fees in this instance may be waived but only with management approval.

HealthTexas believes that a good physician/patient relationship is based upon understanding and good communication. Questions about cancellation and no show fees should be directed to the clinic manager.


Please sign that you have read and understand this Cancellation and No Show Policy.


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Notice of Privacy Practices & Communication Consent

You may review the HealthTexas Medical Group of San Antonio's Notice of Privacy Practices at the link below:

HealthTexas Notice of Privacy Practices


Please sign below that you received a copy of the HealthTexas Medical Group of San Antonio’s Notice of Privacy Practices.

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Communication Consent Form

HealthTexas Medical Group has offered to communicate with you via patient portal, secure messaging, and telephone voice mail and text1 . This communication may include any of the following:

  • Appointment information/directions/reminders
  • Recommendation for follow-up
  • General educational/treatment information
  • Financial/billing information such as invoices and receipts
  • Wellness Report
  • Treatment summary for insurance purposes
  • Test result data
  • Specific treatment information
  • Medication list

By acknowledging and signing this consent form, you are granting permission to HealthTexas Medical Group and any related affiliates or third-parties to contact you on the mobile and/or land line number(s) listed below. Please note that contacts may be made as a direct dial call or through the use of text messages, pre-recorded or artificial voice messages, and/or the use of an automated telephone dialing system or auto-dialer. In addition, depending on your mobile service plan, message and data rates may be assessed by your mobile provider.

You may withdraw consent or opt-out at any time by providing written notice to any HealthTexas Medical Group Clinic location or administration office.


Do you consent to allow HealthTexas Medical Group and any related affiliates or third-parties to contact you via the email and/or the mobile/land line number(s) you have listed?*
Sign below only if you consent
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Is the Patient Under the age of 18 years old?
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1Be advised that email, telephone voice mail and text communications are not secure and may be intercepted or disclosed to third parties.


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