Patient Forms & Notices
Patient Forms
New Patient Demographics Form
Vanderbilt Forms
Teachers
Parents
Medical Records Forms
Corporate office located in
Cleveland
307 North William Barnett Ave
Cleveland, Texas 77327
Fax: 346-414-3084
Email: medicalrecords@hcset.com
Behavioral Health Forms
Sliding Fee Scale Discount Program Application
Telepsychiatry/Telemedicine Forms
Notice of Privacy Practices
The Health Center of Southeast Texas “Notice of Privacy Practices” provides information about how my health information may be used and disclosed. The “Bill of Rights and Responsibilities” provides information to promote the interests and wellbeing of patients and to promote better communication between the patient and the health care provider. A copy of the notices will be printed upon my request. I understand the terms of the Notice may change and that a copy of the revised Notice will be posted in the office lobby.
You may view our full Notice of Privacy Practices by clicking HERE
AI USE DISCLOSURE — TRAIGA (Eff. 1/1/2026)
Health Center of Southeast Texas may utilize photography or video recording in the course of care for the purpose of patient treatment. If your provider takes photographs or video recordings during your treatment, those images will be stored as a part of your medical record in accordance with our policies protecting patient confidentiality. In addition, your providers may record conversations you have with him/her regarding your condition and possible treatments. The recording will be erased, and the summary notes will be stored in the Health Center of Southeast Texas medical record
Patient Access
Patient Rights and Policies
At your first appointment and then annually, you will be asked to sign an acknowledgment that you have been offered a copy of our PRIVACY POLICY.
Good Faith Estimate
You have the right to receive a “Good Faith Estimate” explaining how much your health care will cost.
Under the law, health care organizations need to give patients who do not have insurance — or who are not using insurance — an estimate of the cost for medical items and services.
- You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services.
- The GFE will be generated for appointments scheduled a minimum of 3 business days prior to the visit.
- A GFE may be requested from your health care organization prior to scheduling an item or service.
- If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
To enable your patient portal to receive your GFE letter please click on the following link >>>
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059.