Medical Forms
Depending on your sex, age, and who you are seeing in our practice, please fill out the forms listed below. Remember that you need to be at our office 15 minutes prior to your scheduled appointment time to register if you are new to our office. Please bring your insurance card with you. If you have a co-pay or payment due, this will be collected prior to your visit.
New Patient Child Ages 2-12
- Pediatric Packet
- HIPAA Signature Page Signed by Parents (If you want both parents to have access to the records, please list both names on the form.)
- Records Release to SONORAN MEDICAL CENTERS from Another Provider
**If someone other than the parent/guardian brings the child to the office, you must complete the Consent for Authorization for Treatment of a Minor, naming that person as the parent/representative.
New Patient Adolescents Ages 13-17
- Teen New Patient Packet
- HIPAA Signature Page Signed by Teen (If you want your parents to have access to your records, please list their names on the form.)
- Records Release to SONORAN MEDICAL CENTERS from Another Provider
**If you come to the office without a parent/guardian, you must have your parent/guardian complete and sign the Consent to Treat a Minor form.
**If you come to the office with an adult other than your parent/guardian, you will need to have your parent/guardian complete the Consent for Authorization for Treatment of a Minor form.
New Patient Adults 18-64
New Patient Females Seeing Dr. Belen for Gynecology
Miscellaneous Forms
- HIPAA Signature Page Signed by a Patient (If you want someone else to have access to your records, please list their names on the form.)
- Arizona Health Information Exchange Notice of Health Information Practices
- Arizona Health Information Exchange Opt-Out Form
- Arizona Health Information Exchange Information
- Consent for Telehealth