Make An Appointment

Make An Appointment

Thank you for your interest in ICNA Relief Medical Clinic Dallas. Before making an appointment, please read through our Eligibility Requirements and HIPAA & Privacy Policy. We look forward to serving you.

Patient Intake Form

Please fill out this form if you are a NEW patient

Click Here

General Appointment Form

Please fill out the Patient Intake Form if you are a NEW patient

Click Here

Psychiatrist Intake Form

Click Here

Eligibility Requirements

You will have to complete the new patient clinic application (attached below) and meet our eligibility requirements prior to scheduling an appointment with a doctor.

Eligibility Requirements (you must):

  • Be between the ages 18 – 64
  • Have no health insurance
  • Have an income level that falls within 250% of the Federal Poverty Level based on the number of people in your household

Required Documents

  1. Identification Documents (any one of the following):
  • Driver’s license
  • DMV ID card
  • Passport
  • Green Card

Chart for income guidelines

Our address is: 10874 Plano Rd #A, Dallas, TX 75238

Our fax number is: 214-602-3510

If you have any questions feel free to call us at 469-291-7411

HIPAA & Privacy Policy

Summary HIPAA Notice of Privacy Practices

The ICNA Relief Medical Clinic complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  The ICNA Relief Medical Clinic protects confidential health care information, known as “Protected Health Information” (PHI).

Below is a summary of your privacy rights under HIPAA.

Please see the attached details.

The ICNA Relief Medical Clinic legal duties and privacy practices regarding your PHI are also included in this Summary Notice.

Summary of Your Privacy Rights

ICNA Relief Medical Clinic may use and give your health information to:

  • Treat you
  • Operate health care services

The ICNA Relief Medical Clinic may use and give your health information for:

  • Law enforcement requests
  • Judicial and administrative proceedings related to legal actions
  • Healthcare fraud and abuse detection or compliance with the law
  • Use by another healthcare provider treating you
  • Government health oversight activities

Reports required by law related to births, deaths or diseases

  • Reports required by law related to neglect and abuse, or domestic violence
  • Notifying a party about exposure to a possible communicable disease
  • Military, national defense and security or other governmental functions
  • Workers’ compensation purposes and in compliance with related laws
  • Averting a serious threat to public health and safety

You have the right to:

  • Inspect or get a copy of your medical record
  • Change information on your medical record if you think it is incorrect
  • Get a list of persons whom The ICNA Relief Clinic shared your PHI
  • Ask The ICNA Relief Medical Clinic to limit the information it shares
  • Ask for a copy of your privacy notice
  • Write a letter of complaint to The ICNA Relief Medical Clinic or the federal government