Patient Forms

Forms can be completed online through the patient portal or you can print them from our website and bring them with you to your appointment.


New Referrals/ Authorization Policy 

An important aspect of having a managed care health plan or HMO Insurance is having your primary care physician assess your health care needs. This step helps your provider to clarify your medical record to properly diagnose the problem and to give you a better chance of being referred to the most appropriate specialty physician. 

**If you seek the services of a specialist without a prior authorized referral, you may be held financially responsible for the entire specialty service. ** 

The office can assist with the HMO Referral Process. You can request through the patient portal for a faster response or contact the office and request a referral authorization prior to any specialty service being rendered. If your insurance requires, we process a referral, we must document the required criteria before processing the referral. If the criteria are met, the referral authorization must be requested and received prior to your specialist visit. It is the patient’s responsibility to become familiar with their insurance policy and its requirements for obtaining referrals. 

So that we may accommodate your requests and needs in a professionally efficient and timely matter we ask that you familiarize yourself with White Oak Medical Associates Policy below. If you have any questions regarding the policy, please ask for clarification. 

White Oak Medical Associates Referral Policy 

– A minimum of 10 business days is needed for this office to process non-emergency referral requests. 
– Emergency referrals will be handled as quickly as possible. 
– It is the patient’s responsibility to make sure that they have complied with the referral policy guidelines of our office and have met the requirements mandated by their health plan. The patient must have an approved and completed referral form or authorization number in hand PRIOR to examination by a specialist or testing performed. 
– Retroactive Referrals WILL NOT be issued. If you are seen by a specialist or facility without the proper referral, your insurance carrier will most likely deny coverage and you will be responsible for charges incurred. If you receive treatment in a hospital emergency room or urgent care facility during a weekend, holiday or after hours, you must report this to our office on the first business day following treatment, so we can provide proper authorization to that facility. 
– If a specialist refers you to another physician or facility you must contact our office for that referral. 

How to Obtain a Referral for the specialist needed: 

  1. Select a specialist – contact your insurance carrier for an In-Network provider listing or ask our staff for a list of recommended specialists in the area to compare. 
  1. Call the specialist’s office and make an appointment (be sure you give yourself at least 48 hours before the appointment so you can obtain a referral) – verify that the specialist is PARTICIPATING with your insurance plan. 
  1. IMMEDIATELY call our office at (713) 714-5376 and select the option for the referrals. We are experiencing a high call volume. If it goes to voicemail please speaking slowly and clearly, and leave the following information: 
    – Your full name (spelling out your last name) and date of birth. 
    – A phone number where you can be reached or where a message can be left. 
    – Name and phone number of the specialist you will be seeing (please give the address and phone number if you have it available). 
    – The reason for your visit to the specialist, the date and time of your appointment. 

Specialist Follow-Up Referral Requests 


In order to ensure the processing for a referral plan authorization, we request that you contact the office at minimum of 10 business days ahead of any scheduled appointments. If the Referrals Specialist does not have enough notice, they will not be able to process same-day referrals requests. Therefore, you may be required to reschedule your specialty care appointment or be held financially responsible. 


Patient Forms

Authorization for Release of Medical Information (PDF) - Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility. Autorización De HIPAA Para Divulgar Información Del Paciente

Authorization and Consent for Treatment (PDF) - All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility. Autorización y Consentimiento Para el Tratamiento

Preferred Contacts (PDF) - Patients are encouraged to complete and return the Preferred Contacts Form but it is not required. Contactos Preferidos

Virtual Visit Policy (PDF) - This policy describes the process for the documentation, maintenance, and transmission of information using virtual visit technology.

Office Policies

Financial Policy (PDF) - This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations. Política Financiera (PDF)

Notice of Privacy Practices (PDF) - Describes how health information about you (as a patient of this Care Center) may be used and disclosed, and how you can get access to your individually identifiable health information. Please review this notice carefully. Aviso de prácticas de privacidad (PDF)

HIPAA Privacy Notice