Premiere Healthcare for Children, Adolescents, and Adults

Forms

Completion of forms, although tedious, is necessary for proper medical care, insurance reimbursement, and regulatory compliance. Some forms are lengthy or may require access to information unavailable during your appointment. To minimize this burden, LifeScape has made its forms available online. Please download, print, and complete all applicable forms and bring them with you to your appointment. New patients should print out and complete the "New Patient Packet" that includes all forms for a first time visit. Existing patients should print out and complete the "Problem Checklist." Please call us at 480-860-5500 if you have any questions or concerns.

NEW PATIENTS			EXISTING PATIENTS
•	New Patient Packet (All forms below combined in a consolidated download)		•	Problem Checklist (must be completed for all LifeScape Visits)
•	Patient Registration		•	Records Release from LifeScape
•	Health History		•	Records Release to LifeScape
•	Consent to Annual Fee
•	Notice of Privacy Practices		TRAVEL CLINIC
•	Acknowledgement of Privacy Practices		•	Pre-travel Questionnaire
•	Records Release to LifeScape
Advanced Directives / Living Will
•	Arizona Compliant Life Care Planning Packet including Durable Health Care Power of Attorney, Living Will, Durable Mental Health Care Power of Attorney, Letter to Agent/Representative,and Advance Medical Directive Forms