Health Center of Southeast Texas |307 North William Barnett AvenueClevelandTX77327 | (281) 592-2224

Patient Forms & Notices

Your Care in Our Hands
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Patient Forms

Here is where you'll find all the necessary paperwork, information, and resources. Please download and complete the appropriate forms before your appointment. You may email your completed form to or bring it with you to your appointment. For instructions on after-hours access, please contact your local office.

New Patient Forms

Coming Soon

To better coordinate your care, please notify the Health Center of any hospital or any emergency department visits.

Medical Records Forms

Medical Records Department -
Corporate office located in
307 North William Barnett Ave
Cleveland, Texas 77327
Fax: 346-414-3084

Telepsychiatry/Telemedicine Forms

Coming Soon

HIPAA/Privacy Practice Notice

Coming soon

Patient Rights and Policies

The Health Center of Southeast Texas is committed to respecting the privacy and confidentiality of each of our patients. In accordance with the standards of medical practice and the Health Insurance Portability and Accountability Act (HIPAA), the Health Center of Southeast Texas has established a Privacy Policy.

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 or call 1-800-985-3059.

Our Mission
Our mission is to provide accessible, compassionate, culturally competent, and quality health care affordable for all, regardless of ability to pay.

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