Patient inquiry for SelectCare of Texas

YES, I would like more information about SelectCare and its TexanPlus products:

Salutation	(Mr., Mrs., Miss, Ms., Dr., Rev.)
First name
Last name
Mailing address
City
State	(out of area residents are not eligible for TexanPlus plans)
Zip code
Daytime telephone (optional)	(including area code)
Other telephone (optional)	(including area code)
E-mail address (required so that we can verify that it is you sending the request)
Your primary doctor's name
Comments or questions to be answered by a SelectCare representative (these questions will NOT be answered by anyone from Northwest Diagnostic Clinic)

By checking this box, I authorize Northwest Diagnostic Clinic to provide SelectCare of Texas with the information indicated above. I understand that NO OTHER INFORMATION about me will be released without my express written permission. NOTE: This protection is available for current patients of NWDC. Any non-patient who fills out this form will have their information sent to SelectCare whether they check the box or not.