Medical Forms

Employer Referral Form

Employer's medical authorization form for contracted and non-contracted services. Please print, sign, and send with the employee for requested services or fax it to (928) 774-0123

Notice of Privacy Policy

Please print and read this form so that you are aware of our privacy policies.  You do not have to bring in the form to your office visit. It is strictly to describe how medical information about you may be used and disclosed, and how you can get access to this information.

Notice of Privacy Practices (NPP) Policy and Financial Policy

Please print and read this form.  You will need to answer question #10, enter the Date and your Signature, and then bring it with you to your first office visit.

Authorization for Release of Confidential Medical Records

This form allows you to request your medical records from another Doctor so that they can be sent to our offices in preparation for your visit.  This will help our Doctors have all the pertinent records of your medical history. Please print this form and take it to your other Doctor or Specialist prior to your office visit.

Medicare Private Health Contract

If you are a Medicare Patient, you will need to fill out this form.  Our medical office does not participate in Medicare.  If you wish to have our office provide care for you, please print and read this policy so that you are aware of the terms of your visit.  Please "DO NOT" sign it, simply read it and bring it in to your office visit.  A "witness" must see you sign the form and then also sign as well.