Forms
To view the forms listed below, you will need Adobe Reader. Download Adobe Reader for free. We do not accept transferred records on CD's. Please request your previous office to print records and mail directly to our office. If you are given a CD please download files and bring a copy to our office.
There is a $10 form fee charged each time and per child for a request to complete a form. A signed release and payment of the fee is required prior to the provider completing. We cannot guarantee the provider can complete your form. Once the request has been handed in & form fee paid the provider will then review your child's chart and if for any reason we cannot complete the form we will refund your money. A sports physical form is free when completed at the time or within 30 days of your child's well check.
If your child has a portal account we can send information directly to you via the portal. You can view visit notes, labs medications, etc. Please call the office to request specialist notes, immunization records & we will upload to your child's portal account. If your child is not set-up on the portal, please call the scheduling line & request an email with a PIN number.
You also can request medical information for your child by printing the release of records form below and completing. Please specify what you are requesting and how you would like to receive. Each child will require a separate form. We do not email full medical records.
BEHAVIORAL HEALTH records must be requested by parent or Legal Guardian. We are unable to obtain these from prior providers due to the HIPAA laws.
Remember ALL requests must have a signed release with an original signature by parent or Legal Guardian in order for us to process. We cannot accept computer generated signatures or requests that are emailed with a phone picture of a signed form. Please make sure to
ATTACH the signed form and EMAIL request
to
aaldama@cactuschildrens.com or FAX
to 602-938-2198.
Remember all requests by email must be sent as an attachment.
** All of the above records will be prepared within 7-10 days upon receipt or payment. Records for patients that have not been to our office in over 3 years may take an additional 10 days to process.
Release of Records
New Patient Forms
- Patient Demographics (PDF)
- Informed Consent (PDF)
- Lab Consent (PDF)
- Permission to Treat (PDF) This form is for you to complete if you are requesting anyone other than parent/legal guardian to bring child in.
- Financial Responsibility (PDF)
- Parenting Policy (PDF)
Formularios para pacientes nuevos
School/Work Forms
Please make sure to complete all 5 pages. Parent and athlete must sign and date and send in with a completed release of record. There is a $10 fee if not completed within 1 month of physical exam. NOW OFFERING $45 PHYSICAL EXAMS if not covered by your insurance.
Family Medical Leave Act: Please make sure to complete and fax this form. There is a $10.00 processing fee that is collected prior to completion. Please remember not all absences meet the FMLA criteria please make sure to review the code of Federal regulation §825.113 Serious health condition, §825.112 Qualifying reasons for leave, general rule, §825.115 Continuing treatment
Social Security Letter Request Form
If you would like to get obtain a social security card the state requires a letter from your child's doctor. Please complete in full and send in the attached signed form. There is a $10 fee so someone from the office will call you to collect. This letter cannot be mailed/emailed as the court requires an original. When it is completed we will call you to pick-up. Child must have been seen within the last year.
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