Helpful Forms: Physician Practice and Medical Records

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Advanced Medical Care for the Whole Family

Health Care Providers

Immunizations & Vaccines

Prescriptions

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Heathcare Providers:

Michael A. Benavidez, D.O.

Daicy Navarro, MS PA-C

Nanette Rueda-Lopez, PA-C

If you're a new patient, please complete the following forms and bring them to your first appointment.

New Patient Information Form

If you would like our team to coordinate care with another physician practice please complete the form below to authorize release of your medical record, or the authorization for another physician practice to disclose information to us:

Release of Medical Record Information Form
Authorization to Disclose Information Form
HIPAA Authorization Form

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Helpful Forms

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