Accepting New Patients

Contact Us

Call (903) 712-3627 for an Appointment

Walk-In appointments welcomed.


Follow our Facebook Page (North Texas Family Health, LLC)


Email us: 

rtempleman@notexfh.com

julie@notexfh.com

kelly@notexfh.com

North Texas Family Health

980 W Van Alstyne Parkway, Van Alstyne, Texas 75495, United States

Clinic Hours

Monday through Thursday 8 am - 5 pm

Friday 8 am - 12 noon.

Patient Forms and Documents

Downloads

The following downloads are part of each patient's medical file and must be updated annually or as information changes.

Speed up you Visit

By downloading and completing the forms below prior to your visit, you can drastically reduce the time of your visit.

Documents and Forms

  1. All patients must have all "New Patient" forms completed and in their patient file.
  2. All patients must have completed "history" files in their patient files
  3. Patients who have Medicare, Medicaid, and Insurance coverage must have completed "Screening" files in their patient file.
  4. School and Athletic Physical forms are to be completed by both the student/athlete and their parent/guardian prior to examination.  Copies are kept on file.
  5. Some forms will require annual or semi-annual revisions to meet insurance or treatment plan requirements.

Downloads

New Patient and Annual Update Forms

Authorization of Disclosure of PHI (pdf)

Download

Controlled Medication Agreement Form (pdf)

Download

Financial Agreement Policy ^N1 (pdf)

Download

HIPAA Patient Information (pdf)

Download

Notice of Privacy Practice (pdf)

Download

Patient's Rights and Responsibilities (pdf)

Download

Patient Introduction Letter (pdf)

Download

Downloads

Medical, Surgical, Family, & Social History Forms

Medical History (pdf)

Download

Social History Allergies (pdf)

Download

Surgical History (pdf)

Download

Family History (pdf)

Download

Downloads

Health Screening Questionnaires (required by Medicare and Most Insurances)

Health Status Questionnaire (pdf)

Download

Alcohol Screening Questionnaire (pdf)

Download

DAST-10 Drug Abuse Screening (pdf)

Download

GAD-7 (Generalized Anxiety Disorder Screening) (pdf)

Download

PHQ-9 Questionnaire (pdf)

Download

Fall Risk Assessment Tool (pdf)

Download

Tobacco Cessation Counseling (pdf)

Download

Downloads

Pre-Participation /Athletic/School Physical Forms

UIL PrePhysFormRvsd1-19 (pdf)

Download

Athletic Physical Emergency Contact Form (pdf)

Download

Concussion Awareness and Policy (pdf)

Download

Heat and Humidity Awareness Policy (pdf)

Download

Privacy Policy

 

Privacy Notice

This privacy notice discloses the privacy practices for North Texas Family Health,  https://notexfh.com, and associated social media pages. This privacy notice applies solely to information collected by North Texas Family Health’s website and associated social media sites. It will notify you of the following:

1. No private health information will be disclosed on the websites, social media sites, or public access sources.

2. Each visitor to the North Texas Family Health website and associated social media sites to provide their name and general location, however any personal information regarding health records, financial records, or private information will not be posted for public view. 

· Patients of North Texas Family Health are encouraged to utilize their “Patient Portal” for sensitive information and questions. 

· North Texas Family Health will not answer or acknowledge any questions or comments associated with any Protected Health Information of the patient of another patient on our web page or any associated social media pages. 

3. Posts will be viewed for content and security for our patients, visitors, and staff. Our editing team does have the duty to remove any offensive posts or information posted on our sites.

· Any misuse of the information presented on our sites or any information that may compromise the security of our patients, visitors, and staff. Violations will be removed from view and the author may be banned from further posting to the sites in question.

· All posts and information presented on our website and associated social media sites are subject to following HIPAA rules and regulations. North Texas Family Health will review all posts and edit them to remain compliant to HIPAA regulations.

Information Collection, Use, and Sharing  North Texas Family Health is the sole owner of the information collected on our website. We only have access to/collect information that you voluntarily give us via site posting, email or other direct contact from you. We will not sell or rent this information to anyone.

North Texas Family Health will use your information to respond to you, regarding the reason you contacted us. We will not share your information with any third party outside of our organization, other than as necessary to fulfill your request.

Unless you ask us not to, we may contact you via email in the future to tell you about specials, new services, upcoming events, or changes to this privacy policy.

Your Access to and Control Over Information  You may opt out of any future contacts from North Texas Family Health at any time. You can do the following at any time by contacting us via the email address or phone number given on our website:

· See what data we have about you, if any.

· Change/correct any data we have about you.

· Have us delete any data we have about you.

· Express any concern you have about our use of your data.

Security  We take precautions to protect your information. When you submit sensitive information via the website, your information is protected both online and offline.

Wherever we collect sensitive information (such as credit card data), that information is encrypted and transmitted to us in a secure way. You can verify this by looking for a lock icon in the address bar and looking for "https" at the beginning of the address of the Web page.

While we use encryption to protect sensitive information transmitted online, we also protect your information offline. Only employees who need the information to perform a specific job (for example, billing, customer service, or post editing) are granted access to personally identifiable information. The computers/servers in which we store personally identifiable information are kept in a secure environment.

If you feel that we are not abiding by this privacy policy, you should contact us immediately via telephone at (903)712-3627 or rtempleman@notexfh.com.