On-Site Lab Tests with no Appointments

Same Day Appointments!

Get Your Flu Shots Now!

En Espanol
En Nuestras Clinicas Ablamos Espanol!

Phoenix Family Medical Clinic
Call us Today!
  • Same Day Appointments
  • Open Saturdays
  • Walk-Ins Welcome
  • Most Plans & AHCCCS Accepted
  • Cold & Flu Clinic
  • Full Service Family Clinic
  • No-Insurance Clinic
  • Affordable & Accessible Medical Care
The Women's Health Institute at Phoenix Family Medical Clinic
  • Same Day Appointments
  • Open Saturdays
  • AHCCCS OK
  • Walk-ins Welcome

Page 1 of 15

New Patient Package

Office Policies and Procedures

We appreciate the confidence you have shown by choosing our office to provide medical care to you and your family. We make every effort to give you the best possible care. In order to achieve this, we ask for your assistance in the following clinic policies.

APPOINTMENTS
Appointments are required to address any/all issues and concerns. Regular office hours are Monday through Friday from 9:00 am – 6:00 pm with lunch from 12 pm – 1:00 pm (hours may vary from time to time). We reserve some appointment times for same day "sick" visits every day. We work hard to accommodate requests for same day appointments, but are not always able to do so. New patients must arrive 30 minutes prior to their appointment time. If you are an established patient, please arrive 10 minutes prior to your appointment time. If you arrive late, we may need to reschedule your appointment.

If you are unable to keep your scheduled appointment, please call our office 24hrs hours ahead to cancel so that your appointment time can be made available to other patients. It is our policy that if you do not show for 3 appointments you will be notified by mail that you will be discharged from the practice. Phoenix Family Medical Clinic reserves the right to bill $25.00 for No-Show appointments.

TEST RESULTS
Our medical assistant will usually contact you by phone regarding your test results to schedule an appointment for follow-up. Due to HIPPA Law we are unable to disclose any medical information with you or any other member of your family. If you have not heard from our office within 15 business days, please contact our office.

MEDICATION REFILLS
We require 72 hours notification for all refill requests. Please do not allow yourself to run out of medication. Your provider requires advance notice, as he/she needs to evaluate your medical records. Narcotic medications will NOT be refilled without an office visit.

REFERRALS
All referrals require an office visit. When your provider wants you to be referred to a specialist, it will take up to 10 business days for completion. If it is an urgent referral, it will be completed within 48 hours. You will receive all the information you need by mail or phone so that you are then able to call and schedule your appointment. If your specialist requires additional visits, it is your responsibility to verify that the specialist is contracted with your insurance prior to your visit.

MEDICAL RECORDS
For all medical record requests, a release form will be provided and must be signed by the patient. Please allow 15 business days to process your request. Your records may be faxed to another physician's office OR made available for you to pick up in our office, Please note: If you are picking up records from our office there is a minimum charge of $15.00 for up to 30 pages.

PHYSICIAN PHONE CONSULT
Our providers do not usually consult patients over the phone. If this becomes a necessity which is not a medical emergency, we reserve the right to charge you a consultation fee (most insurance plans do not cover phone consultations, so therefore this charge will be your responsibility).

INSURANCE
It is the patient's responsibility to understand their insurance plan benefits. We will try to assist you when possible with what is and is not covered. The patient is responsible for services/items that the insurance does not cover.

PAYMENTS
The patient is responsible for payment of each office visit. If you have insurance, our billing department will file the claim with them as a courtesy. Please have your insurance card with you at each visit. Co-payments and payments are always required on the day of service. If you do not bring your payment with you, we reserve the right to reschedule your appointment. Patients without insurance will need to pay for their service on the day it is rendered. Please pay with cash, credit or debit card. We do not accept checks. A 33% fee will be added to accounts that are sent over to collections.

AFTER-HOURS EMERGENCIES
If you have a true medical emergency, please call 911 or go to the nearest emergency room to receive medical assistance immediately.

I have reviewed the policies listed above in their entirety.

Patient Name(*)
Please enter your full name

 
Patient Information/Informacion del Paciente

Date(*)
Please enter today's date

Email address(*)
Please provide a valid email address

Name/Nombre(*)
Please enter your name

SSN/Numero de Seguro Social(*)
Please enter your SSN

Age/Edad(*)
Please enter your age

Sex/Sexo(*)
Please select an option

Marital Status/Estado Civil(*)
Please enter your marital status

DOB/Fecha de Nacimiento(*)
Please enter your date of birth

Home Phone/Numero de Casa(*)
Please enter your home phone

Cell Phone/Numero de Cellular(*)
Please enter your cell phone

Address/Direccion(*)
Please enter your address

Apartment/Apartamento
Invalid Input

City/Ciudad(*)
Please enter your city

State/Estado(*)
Please enter your state

Zip/Codigo Postal(*)
Please enter your zip

Occupation/Ocupacion(*)
Please enter your occupation

Employer/Empleador(*)
Please enter your employer

If need arises, the doctor/receptionist may leave a message on my / Si necesitan, el doctor/recepcionista puede dejar mensaje en mi(*)
Please select an option

Family Name/Nombre de Familiar
Invalid Input

 
Spouse or Emergency Contact Information (or Parent/Guardian if Patient is Child)

Name/Nombre(*)
Please enter your name

SSN/Numero de Seguro Social(*)
Please enter your SSN

Age/Edad(*)
Please enter your age

Sex/Sexo(*)
Please select an option

Marital Status/Estado Civil(*)
Please enter your marital status

DOB/Fecha de Nacimiento(*)
Please enter your date of birth

Home Phone/Numero de Casa(*)
Please enter your home phone

Cell Phone/Numero de Cellular(*)
Please enter your cell phone

Address/Direccion(*)
Please enter your address

Apartment/Apartamento
Invalid Input

City/Ciudad(*)
Please enter your city

State/Estado(*)
Please enter your state

Zip/Codigo Postal(*)
Please enter your zip

Occupation/Ocupacion(*)
Please enter your occupation

Employer/Empleador(*)
Please enter your employer

 
Medical Insurance Information/Informacion del Seguro Medico

Primary Insurance Company Name/Nombre del Seguro Medico Primario(*)
Please enter your insurance details

Member ID #/ # de ID de Miembro(*)
Please enter your insurance details

Group Number/Numero de Grupo(*)
Please enter your insurance details

Subscriber Name/Nombre del Encargado(*)
Please enter your insurance details

DOB/Fecha de Nacimiento(*)
Please enter your date of birth

Secondary Insurance Company Name/Nombre del Seguro Medico Primario(*)
Please enter your insurance details

Member ID #/ # de ID de Miembro(*)
Please enter your insurance details

Group Number/Numero de Grupo(*)
Please enter your insurance details

Subscriber Name/Nombre del Encargado(*)
Please enter your insurance details

DOB/Fecha de Nacimiento(*)
Please enter your date of birth

Please make sure you update your information with us if there are any changes. Thank you.
Por favor de informarnos si ay algun cambio en su informacion. Gracias.

 
Health History Questionnaire
All questions contained in this questionnaire are strictly confidential and will become part of your medical record.

Name(*)
Please enter your name

DOB(*)
Please enter your date of birth

Marital Status(*)
Please enter your marital status

Previous or referring Doctor(*)
Please enter your previous or referring doctor

Date of last physical exam(*)
Please enter the date of your last physical exam

 
Personal Health History

Childhood Illness
Invalid Input

List any medical problems that other doctors have diagnosed
Invalid Input

Surgeries (enter Year, Reason & Hospital)
Invalid Input

Other Hospitalizations (enter Year, Reason & Hospital)
Invalid Input

Have you ever had a blood transfusion?(*)
Please select an option

List your prescribed drugs and over the counter medication, such as vitamins and inhalers (enter Name of the Drug, Strength & Frequency Taken)
Invalid Input

Allergies to Medications (enter Name of the Drug & Reaction you had)
Invalid Input

 
Health Information and Personal Safety
All questions contained in this questionnaire are strictly confidential and will become part of your medical record.

Exercise
Invalid Input

Are you dieting?
Invalid Input

Caffeine
Invalid Input

No. of cups/cans per day?
Invalid Input

Do you drink alchohol?
Invalid Input

How many drinks per week?
Invalid Input

Do you use tobacco?
Invalid Input

Do you currently use recreational or street drugs?
Invalid Input

Are you sexually active?
Invalid Input

If yes, are you trying for a pregnancy?
Invalid Input

Any discomfort with intercourse?
Invalid Input

Would you like to speak with your provider about your risk of HIV/AIDS?
Invalid Input

 
Family Health History
Father

Age
Invalid Input

Significant Health Problems
Invalid Input

Mother

Age
Invalid Input

Significant Health Problems
Invalid Input

Siblings

Invalid Input

Significant Health Problems
Invalid Input

Invalid Input

Significant Health Problems
Invalid Input

Invalid Input

Significant Health Problems
Invalid Input

Invalid Input

Significant Health Problems
Invalid Input

Invalid Input

Significant Health Problems
Invalid Input

Invalid Input

Significant Health Problems
Invalid Input

Children

Invalid Input

Significant Health Problems
Invalid Input

Invalid Input

Significant Health Problems
Invalid Input

Invalid Input

Significant Health Problems
Invalid Input

Invalid Input

Significant Health Problems
Invalid Input

Grandfather (Maternal)

Age
Invalid Input

Significant Health Problems
Invalid Input

Grandmother (Maternal)

Age
Invalid Input

Significant Health Problems
Invalid Input

Grandfather (Paternal)

Age
Invalid Input

Significant Health Problems
Invalid Input

Grandmother (Paternal)

Age
Invalid Input

Significant Health Problems
Invalid Input

 
Other Problems

Check if you have, or have had, any symptoms in the following areas to a significant degree
Invalid Input

Recent changes in
Invalid Input

Other pain/discomfort
Invalid Input

 
Health Information and Personal Safety
Women Only

Age at onset of menstruation
Invalid Input

Date of last menstruation
Invalid Input

Period every (days)
Invalid Input

Heavy periods, irregularity, spotting, pain, or discharge?
Invalid Input

Number of pregnancies
Invalid Input

Number of live births
Invalid Input

Are you pregnant or breastfeeding?
Invalid Input

Have you had a D&C, hysterectomy, or Cesarean?
Invalid Input

Any urinary tract, bladder, or kidney infections within the last year?
Invalid Input

Any blood in your urine?
Invalid Input

Any problems with control of urination?
Invalid Input

Any hot flashes or sweating at night?
Invalid Input

Do you have menstrual tension, pain, bloating, irritability or other symptoms at or around time of period?
Invalid Input

Experienced any recent breast tenderness, lumps, or nipple discharge?
Invalid Input

Date of last pap and rectal exam?
Invalid Input

 
Health Information and Personal Safety
Men Only

Do you usually get up to urinate during the night?
Invalid Input

If yes, number of times
Invalid Input

Do you feel pain or burning with urination?
Invalid Input

Any blood in your urine?
Invalid Input

Do you feel burning discharge from penis?
Invalid Input

Has the force of your urination decreased?
Invalid Input

Have you had any kidney, bladder, or prostate infections within the last 12 months?
Invalid Input

Do you have any problems emptying your bladder completely?
Invalid Input

Any difficulty with erection or ejaculation?
Invalid Input

Any testicle pain or swelling?
Invalid Input

Date of last prostate and rectal exam?
Invalid Input

 
Health Information and Personal Safety
Mental Health

Is stress a major problem for you?
Invalid Input

Do you panic when stressed?
Invalid Input

Do you have problems with eating or your appetite?
Invalid Input

Do you cry frequently?
Invalid Input

Have you ever seriously thought about hurting yourself?
Invalid Input

Do you have trouble sleeping?
Invalid Input

Have you ever been to a counselor?
Invalid Input

Do you feel depressed?
Invalid Input

Have you ever attempted suicide?
Invalid Input

 
Acknowledgement of Receipt of Notice of Privacy Practices (HIPAA)

You may refuse to sign this Acknowledgement

I have received a copy of this Notice of Privacy Practices.

Patient Name(*)
Please enter your full name

Patient Record of Disclosure

In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual's home.

I wish to be contacted in the following manner (check all that apply):

Home Telephone
Please enter your full address including zip

Invalid Input

Work Telephone
Please enter your date of birth

Invalid Input

Written Communication
Invalid Input

SSN
Please enter your telephone no.

 
Patient Authorization to Disclose Personal Information

Phoenix Family Medical Clinic/ Phoenix Clinica Familiar is authorized to(*)
Please select an option

Physician(*)
Please enter the name of your physician

Phone #(*)
Please enter your physician's phone no.

Fax #(*)
Please enter your physician's fax no.

Address(*)
Please enter your physician's address

I authorize release of the following medical records(*)
Please select an option

Invalid Input

I released Phoenix Family Medical Clinic/ Phoenix Clinica Familiar and the Recipent/Disclosure listed above, and any of their providers and staff from all responsibility or liability that may arise from this authorization. I may withdraw this authorization at any time by giving written notification to Phoenix Family Medical Clinic/ Phoenix Clinica Familiar, provided that I do so in writing and to the extent that you have already disclosed the information in reliance on this authorization.

This Authorization expires on
Invalid Input

(Optional) If no expiration date is given, then this authorization shall remain in effect for a period reasonably needed to complete the request.

 
Oxycodone/Narcotic Pain Medication Guidelines

From: Dr. Napoleon Ortiz, MD

  • This clinic follows strict rules on prescribing Narcotic Pain medication.
  • We discourage all long term use of narcotic pain medication including Oxycodone.
  • If you are here just to seek narcotic pain medication or Oxycodone, please be aware that this clinic will not prescribe those medications.
  • All Oxycodone/ narcotic pain medication prescriptions are FINAL. There will be no refills at all, under no circumstances.
  • We believe that Narcotics Pain killers like Oxycodone do not heal or cure anything.


If you do not agree with these guidelines, we request that you let the front office person know, so she cancels your appointment. We thank you for your patience in reading this memo.

Patient Name(*)
Please enter your full name

Preferred clinic location(*)
Please select your preferred clinic location