Patient Forms & Notices
Health Center of Southeast Texas | 307 North William Barnett Avenue, Cleveland, TX 77327 | (281) 592-2224
Patient Forms
New Patient Demographics Form
To better coordinate your care, please notify the Health Center of any hospital or any emergency department visits.
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
HIPAA/Privacy Practice Notice
HIPAA/Privacy Practice Notice
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.