Helping people gain better

control of their health

Patient Forms

 

The following forms and corresponding instructions have been provided for your convenience. You may also choose to print the appropriate forms, fill it out, and bring with you to your next appointment

Jump to section:

to New Patient Forms
to Existing Patient Forms
to Formas en Español
to Other Forms

 

New Patient Forms

Texas Diabetes & Endocrinology has partnered with Phreesia to help you save time registering for your appointment. Be on the lookout for an e-mail or text message a few days before your appointment from Phreesia, our new mobile check-in platform. Our new system allows you to check-in & register from any smartphone, tablet, or computer from the privacy of your own home.

Checking in with Phreesia saves you time and ensures your information is always up to date! Have questions? Feel free to contact our scheduling department at 512-458-8400. Option 2.

New Patient Forms
Notice of Privacy Practices
Medical Records Release of Information
Email Consent Form

To have medical records released, please complete the Medical Release of Information Authorization form below online. If you would prefer to print and fill out the form, you may mail the completed authorization to 110 Deer Ridge Drive, Round Rock, TX 78681, ATTN: Medical Records. You can also fax the completed form to (512) 372-1074, ATTN: Medical Records. Questions regarding the release of medical information can be addressed to our Medical Records Department, at (512) 458-8400, option 5 or email medicalrecords@texasdiabetes.com.

 

Existing Patients

Thank You for Being a Patient of Texas Diabetes & Endocrinology, P.A. We are Proud to Serve You. Keeping your information updated helps us stay on track with your needs. Look out for an e-mail or text message a few days prior to your appointment from Phreesia, our new mobile check-in platform. Our new system allows you to check-in from any smartphone, tablet, or computer from the privacy of your own home. Checking-in with Phreesia saves you time and ensures your information is always up to date! Have questions? Feel free to contact our scheduling department at 512-458-8400. Option 2.

You may also choose to print the forms, fill it out, and bring it with you to your next appointment.
When you return to our office, it is important that you always:

  • Bring your current insurance card(s).
  • Update us regarding any changes to your address or phone number.
  • Update us regarding any changes in prescription medications, over-the-counter medications or supplements you take.

Existing Patient Forms
Medical Records Release of Information
Email Consent Form

To have medical records released, please complete the Medical Release of Information Authorization form below online. If you would prefer to print and fill out the form, you may mail the completed authorization to 110 Deer Ridge Drive, Round Rock, TX 78681, ATTN: Medical Records. You can also fax the completed form to (512) 372-1074, ATTN: Medical Records. Questions regarding the release of medical information can be addressed to our Medical Records Department, at (512) 458-8400, option 5 or email medicalrecords@texasdiabetes.com.

 

Formas en Español

Los pacientes nuevos pueden ahorrar tiempo durante su primera cita completando el formulario de registro de pacientes antes de su visita. Simplemente haga clic en los formularios correspondientes a continuación y complete su información en línea. ¡Es así de fácil!
También puede imprimir estos formularios, completar la información solicitada y llevar el formulario completado a su cita. Por favor llegue 15 minutos antes de la hora programada para su cita. ¿Tener preguntas? No dude en comunicarse con nuestro departamento de programación al 512-458-8400, opción 2.

Formularios para pacientes nuevos
Aviso de Prácticas de Privacidad

Mantener su información actualizada nos ayuda a mantenernos en línea con sus necesidades. Si ha tenido algún cambio desde su última visita, simplemente haga clic en el formulario a continuación y complete la información en línea. También puede optar por imprimir los formularios, completarlos y llevarlos a su próxima cita.

Formularios de pacientes existentes

Para que se divulguen los registros médicos, complete el formulario de Autorización de Divulgación de Información Médica a continuación en línea. Si prefiere imprimir y completar el formulario, puede enviar la autorización completa a 110 Deer Ridge Drive, Round Rock, TX 78681, ATTN: Registros médicos. También puede enviar por fax el formulario completado al (512) 372-1074, ATTN: Registros médicos. Las preguntas relacionadas con la divulgación de información médica pueden dirigirse a nuestro Departamento de Registros Médicos, al (512) 458-8400, opción 5 o por correo electrónico medicalrecords@texasdiabetes.com.

Si solicita que sus registros se envíen por correo electrónico, complete también el Formulario de consentimiento por correo electrónico. Nuestro objetivo es proporcionarle copias completas de sus registros de manera oportuna.

Correo Electronico formulario de consentimiento.

Autorización de retiro de pago automático
Fallar la cita- autorización de pago
Acuerdo de Plan de Pago
Responsabilidad financiera del paciente

Other Forms Available

No-Show Authorization of Payment
Notice of Nondiscrimination

Back to top

LATEST NEWS
seperater
Read All posts

Make an Appointment border Call us at: (512) 458-8400, option 2 or Contact us border