Patient Forms & Policies

Online Forms

• Request an Appointment

Download Forms

• Notice of Privacy Practices
• Authorization for Release of Records
• Cancer Family History Questionnaire
• Disclosure Statement for Medical Power of Attorney
• Patient Authorization for Use-Disclosure of PHI
• Patient Financial and Privacy Policies

Billing & Insurance

Hospital Affiliations

Baylor All Saints Medical Center in Fort Worth

Texas Health Harris Hospital in Downtown Fort Worth

Texas Health Harris Outpatient Surgery Center

Baylor Surgical Hospital of Fort Worth

Baylor Surgicare

Good Faith Estimate Notice

The federal “No Surprises Act” grants consumers the right to receive a “Good Faith Estimate” explaining how much their medical and mental health care will cost. Under the law, health care providers, including psychotherapists, must give clients who don’t have insurance or who are not using insurance an estimate of the expected charges for treatment services.

The act also requires healthcare providers, including psychotherapists, to inform their clients of this right. Additionally, this act requires that information regarding the availability of a “Good Faith Estimate” must be prominently displayed on the website of all health care providers, including psychotherapists.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy services.

You can ask all of your health care providers, including your therapist and other providers from whom you seek treatment, for a Good Faith Estimate before you schedule a service.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises/.