Patient Form


Eixsys Healthcare System, Inc.

Clinic Hours: Every Saturday 10AM to 1PM

Location: 600 Round Rock West Drive Suite 204, Round ROck, TX 78681

NOTICE: Due to COVID-19 all patient visits are scheduled through video conferencing.

Our mission is to serve the underserved and indigent population. If the patient is uninsured, lost their job and poor (living below 133% Federal Poverty Level) then doctor's visit is free and the cost will be mainly covered by "Zakat ul-maal - Islamic chairty" or other donations received. We ask the patient to take some responsibility and pay for their blood work, radiology, medications or any referrals made to specialist or surgical centers. If patient's household income is above 133% federal poverty level then we ask the patient to pay minimum of $20 for their visit. Please complete the entire application to best of your knowledge.You will receive an automated confirmation text or email two days prior to the appointment. We aim to keep EVERYONE on time, so we ask that your smart device or computer is setup for the video.NOTE: Patients who are more than 5 minutes late after their scheduled appointment time or with incomplete paperwork will be asked to reschedule their appointment. It is our policy to charge patients an inconvenience fee of $20 if they do not keep their scheduled appointment or cancel with less than 24 hours’ notice. Thank you for choosing our clinic. We look forward to serving your medical needs. Should you have any questions, please contact our office at 512-333-0895.

* Terms of Use

* Please upload your goverment issued ID in PDF or jpeg format


Languages other than English

LEGAL GUARDIAN (If Patient is under 18)


Please upload your Medical Report in PDF or jpeg format

EIXSYS Healthcare System

Notice of Privacy Practices

This notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment or healthcare operations and for the purposes permitted by law. Uses and Disclosures of Protected Health Information Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your healthcare and any related services. We will also disclose your protected health to other physicians who may be treating you, or with other medical providers whom you have signed release of protected health information, or specific individuals you have identified in the “Exceptional Authorization” below

Exceptional Authorization

I authorize the release information including the diagnosis, records, examination rendered to me claims information. This information may be released to:

* This release of information will remain in effect until terminated by me in writing

Other Permitted and Required Uses and Disclosures that may be made without your authorization or opportunity to agree or object:

We may use or disclose your protected health information in the following situations without your authorization or providing you the opportunity to agree or object. These situations include:

Required by law:

We may use or disclose your protected health information to the extent that is required by law. The use or disclosure will be made in compliance with law and will be limited to the relevant requirements of the law. You will be notified, if required by law, of any such uses or disclosures.

Public Health:

We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. For example, the disclosure may be made for the purpose of preventing or controlling disease, injury, or disability.

Communicable Diseases:

We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

Abuse or Neglect:

We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your information if we believe that you have been a victim of abuse, neglect, or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

Respond to organ and tissue donation requests:

We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director:

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Health Research:

We can use or share your information for health research.

Respond to lawsuits and legal actions:

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Changes to the Terms of this Notice:

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

Our Responsibilities:

We are required by law to maintain the privacy and security of your protected health information. We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information. We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. HIPAA ACKNOWLEDGMENT OF RECEIPT I have been given the opportunity to read this Notice of Privacy Policy. I understand that Eixsys Healthcare System will only use and/or disclose PHI (Protected Health Information) for treatment, payment or healthcare operations.

Patient/Legal Guardian Signature

EIXSYS Healthcare System

Consent to Treat and Healthcare Agreement

Consent to treat:

I hereby consent to evaluation, testing, and treatment as directed by my physician or his/her designee. I understand that EIXSYS Healthcare System serves as a teaching facility at times, and therefore, I may be attended to by students and residents affiliated with various educational programs. I understand that this consent to treat will be valid for each visit I make to EIXSYS Healthcare System until revoked by me in writing.

Consent to Release Information:

acknowledge that EIXSYS Healthcare System may release my protected health information as necessary for treatment and healthcare operations, and acknowledge that EIXSYS’s Notice of Privacy Practice provides information on how my protected health information may be used and/or disclosed for these purposes. I understand that protected health information pertains to my diagnosis and/or treatment, and includes, but is not limited to, information related to my diagnosis, health history, prognosis, treatment, mental illness (excluding psychotherapy notes), use of alcohol or drugs, prescriptions, and laboratory test results, including HIV or the diagnosis of AIDS. I acknowledge and consent to allow EIXSYS Healthcare System to use health information exchange systems to electronically transmit, receive, and/or access my medical information, which may include, but is not limited to, treatments, prescriptions, labs, medical and prescription history and other protected health information.

Accidental Exposure to Health Care Worker:

I understand that Texas Law provides, and I give consent, that in the event a healthcare worker is exposed to my blood or body fluids, my blood may be tested for HIV and other communicable diseases, at no cost to me.

Notice of Privacy Practice:

I acknowledge receipt of the “Notice of Privacy Practices” from EIXSYS Healthcare System.


Patient/Responsible Party Signature