Rowlett-Obstetrics/Gynecology

:: BIOGRAPHY - DR. MONIKA T. HEARNE

Monika T. Hearne, M.D., F.A.C.O.G, is Board Certified by the American Board of Obstetrics and Gynecology

Specialty		Medical School
Obstetrics and Gynecology		University of Texas Medical Branch School of Medicine Galveston, Texas
Residency		Residence
Orlando Regional Medical Center Orlando, Florida		Dr. Hearne lives in Sunnyvale with her family.
Memberships
American College of Obstetricians and Gynecologists American Medical Association Texas Medical Association

:: BIOGRAPHY - DR. JEFFREY MYERS

Jeffrey Myers, M.D., F.A.C.O.G, is Board Certified by the
American Board of Obstetrics and Gynecology

Specialty		Medical School
Obstetrics and Gynecology		University of Texas Southwestern Medical School Dallas, Texas
Residency		Residence
Cook County Hospital Chicago, Illinois		Dr. Myers lives in Rowlett with his family.
Memberships
American College of Obstetricians and Gynecologists

:: FORMS

Adult New Patient
For adults (age 16+) with a new patient appointment

Financial Policy
Explains payment of services

Receipt and Notice of Privacy Practices
Describes how medical information about you may be used and disclosed and how you can access this information. HIPAA requires all patients to complete this form.
(Para obtener este formulario en español, por favor oprima aquí)

Medical Release
Form authorizing healthcare provider to release your medical information to Lake Pointe Medical Partners
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Medical Information Release
Authorizes Lake Pointe Medical Partners to release your medical information to specific entities.
(Para obtener este formulario en español, por favor oprima aquí)

Red Flags Payment Permission Form
Form authorizing a patient the use of Medical Flex card, personal credit card, or personal check to pay for the services that they receive at Lake Pointe Medical Partners
(Para obtener este formulario en español, por favor oprima aquí)

Request for Correction / Amendment to Record
Allows you to request a correction / amendment to your medical record.

Know Your Benefits
This pamphlet can assist you in learning about your insurance benefits, including questions to ask your provider.
(Para obtener este formulario en español, por favor oprima aquí)

:: SERVICES OFFERED :: HOSPITAL AFFILIATION

6800 Scenic Drive
Rowlett, TX 75088
[t] (972) 412-2273

www.lakepointemedical.com