Patient Forms

New patients will be asked to complete the following forms. You may download and print these forms using the links below. Please bring the completed forms to the appointment. The forms use Adobe/PDF format. [Download/printing help for PDF forms]

• Medical History
• AUA Prostate Symptom Score Questionnaire
• Incontinence Symptom Questionnaire
• Assignment of Benefits/Acknowledgement of Privacy Notice

What to Bring to Your Appointment

• Your insurance card
• Physician referral forms, if required by insurance
• List of prescriptions and/or over-the-counter medication, including dose and frequency
• Information about your medical and surgical history
• Recent x-rays or relevant records

Insurance and Payment Information

William H. Bordelon, MD, PA, is a provider for Medicare and most major insurance plans, and provides insurance billing. You are responsible for charges that are not covered by your insurance, at the time of your appointment.

Your insurance company may require a co-payment at the time of your appointment. When necessary, our staff will work with patients to set up a payment plan.

If you have questions regarding billing or which insurance plans we accept, please call us at the phone number below. Questions regarding insurance coverage and benefits should be directed to your employer or insurance company.

Hospital Affiliations

• Baptist/ St. Anthony's Hospital
• Northwest Texas Hospital
• Amarillo VA Health Care System

Privacy Practices

Notice of Privacy Practices for William H. Bordelon, MD, PA
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.