Patient Forms

If you would like to have your medical records sent to us please download.

Request For Release Of Records.

Bienvenidos a nuestra clinica
Bienvenidos. Para que su primera visita con nosotros sea más eficiente; por favor imprima, llene y triga este documento, junto con su tarjeta de seguro medico, identificación con fotografía a su visita. Todos los co-pagos, deducibles y el dinero adeudado se colectara en el momento de la visita.
Bienvenidos_RFMC.pdf.pdf
Adobe Acrobat document [223.3 KB]

Welcome To Our Office Adult Sign-in Forms
Welcome. To make your first visit with us more efficient; please print, fill out and bring this document along with your Insurance Card, and Photo ID to your visit. All Co-pays, Deductibles and money due will be collected at the time of the visit. We look forward to serving you.
Welcome_RFMC.pdf.pdf
Adobe Acrobat document [201.5 KB]

New Minor Sign-in Forms
Welcome. To make your first visit with us more efficient; please print, fill out and bring this document along with your Insurance Card, and Photo ID to your visit. All Co-pays, Deductibles and money due will be collected at the time of the visit. We look forward to serving you.
New Minor.pdf
Adobe Acrobat document [277.7 KB]

New Request For Release of Records.pdf
Adobe Acrobat document [273.2 KB]

Telemedicine Consent Form
RFMC Telemedicine consent.pdf
Adobe Acrobat document [109.4 KB]

How to get started with Healow TeleVisits

Cómo iniciar sus consultas con Healow TeleVisits

We are currently getting our credentials with Insurance companies. We will be updating periodically, call our office to check your insurance. You can also email us your Insurance company name and we can make sure we request to be on your insurance plan.

We will also see self-pay patients. Information will be available through the office manager.

Thank you for your patience as we get our office up and running.

Current Insurances accepted:

1- Aetna

2- Cigna

3- United Health

4- Humana

5- Blue Cross Blue Shield

6- Medicare (traditional) others check with Office Manager

7- MHealth Memorial Hermann

8- Marketplace Insurance

...awaiting approval of other insurances.

Check in with us if you have any questions.

Payment and Insurance Information

Don't forget to bring your insurance information with you in order to register and treat you promptly, we request that our patients bring their current insurance information with them for each visit. Please note Copayments, Cash payments and deductibles are due at time of your visit.

We accept most types of health insurance and self-pay patients.

We accept most Credit Cards, Debit Cards, and Cash. No Personal Checks Please.