New Patient Forms Packet

New Patient Forms Packet — English**
New Patient Forms Packet — Spanish**

Pediatric Cardiology Form

New Patient Form — Pediatric Cardiology**

Referral Forms for Healthcare Professionals

New Patient Referral Form – Maternal-Fetal Medicine
New Patient Referral Form – Pediatric Cardiology
New Patient Referral Form – From Obstetrician

Medical Records Release Forms

Medical Records Release Form – From FCC
Medical Records Release Form – From Outside Facilities

**To submit this form digitally, download the PDF provided above and fill in your responses, then select “Submit Form” on the final page. You should receive a prompt to select your email address, then you will be able to submit it.

Additional Information

Office visits are by appointment only. Please call us to schedule a visit.

Appointment Line

(972) 566-5600

Cancellation & No-show Policy

When you make an appointment with us, we reserve a significant amount of time specifically for your consultation. Unfortunately, when a patient doesn’t show up for their scheduled appointment, another patient loses an opportunity to be seen.

Please phone our office as soon as you are aware that you will be canceling your appointment. If you phone our office after hours, please leave a message to cancel or reschedule and we will confirm with you by phone on the next business day.

Cancellation charges are listed below. They are not covered by insurance and are due and payable prior to any future appointments. Patients who miss appointments because they have delivered are not charged a cancellation fee.

Required Cancellation Notice: 24 hours
Cancellation Fee: $25

Participating Insurance Carriers

  • Aetna
  • BlueCross BlueShield Texas
  • United Healthcare

These are just a few insurance carriers that Fetal Care Center Dallas has contracts for service. Please check with your insurance plan to ensure covered services or limits in your policy. It is your responsibility to understand the provisions, limits, and requirements of their individual benefit plan(s) and advise us accordingly.

Patients are responsible for any bills not paid by their insurance. If your plan denies payment for services because

  • a plan requirement was not met,
  • services were considered “non-covered,”
  • the plan benefits were exceeded,
  • care was considered medically unnecessary, or
  • treatment is considered experimental,

among other reasons, you will still be held accountable for those charges. Furthermore, if ‘clean claims’ submitted to an insurance carrier are not paid within the 30-day limit established by the Texas Prompt Payment Regulations, FCCTX reserves the right to bill you directly for our services.