Patient Resources

Below this, you will find all our printable office forms we use at Lillo Family Medicine. You may either bring these forms with you before or at the time of your appointment. You may also mail these forms back to us at 3501 N. Scottsdale Road Suite 346, Scottsdale, AZ 85251-5632. You may also fax these forms to our front office fax 480-867-4890.

Advance Beneficiary Notice (ABN)

An ABN (Advanced Beneficiary Notice) is a written notice from Medicare (standard government form CMS-R-131), given to you before receiving services, notifying you: • Medicare may deny payment for that specific procedure or treatment. • If Medicare denies payment, you will be responsible for full payment. We encourage you to check option 1 sign and date. If you check option 2, Lillo Family Medicine may decide to not provide the services, or you may be held liable for payment. Please print, fill out and return this form and return to Lillo Family Medicine.

Download Form

Patient Registration

In order to help us serve you better, the patient may download, fill out, and bring their updated demographics with them to their appointment at least once per calendar year.

Download Form

Health History

New patients or existing patients who have not seen Dr. Lillo within the last three years can save time at their appointment by completing the Health History packet prior to their visit. Simply print out the health history packet, fill in the information requested and bring the completed packet with you to your appointment.

Download Form

Patient Consent (HIPAA)

This notice describes how medical information about you may be used or disclosed and how you can get access to this information. Please review it carefully, sign, date and bring with you to your appointment.

Download Form

Medical Release

You may use the following form to release your medical records from Lillo Family Medicine to another facility or you can request them for yourself. Please print the release, fill out the information requested and return to Lillo Family Medicine.

Download Form

Medical Request

You may use the following form to request your medical records from another facility to be sent to Lillo Family Medicine. Please print the request, fill out the information requested and return to Lillo Family Medicine./p>

Download Form

Medicare Annual Wellness Assessment

An annual wellness assessment is a yearly appointment with your primary care provider to create or update a personalized prevention plan. Some services that may be included in your visit is an EKG, lab work, blood pressure check and going over your health history. Please print this packet, fill out the information requested and bring with you to your visit.

Download Form

Third Party Release

A third-party release is a medical document that gives healthcare professionals permission to share patient medical information with other parties. If you, the patient, would like to release your information to another party, print this form and return to Lillo Family Medicine.

Download Form

Address

Lillo Family Medicine
3501 N. Scottsdale Rd, Suite 346
Scottsdale, AZ 85251

Contact numbers

Phone: 480-945-3873
Main Fax: 480-945-5992
Front Fax: 480-867-4890

Opening Hours

Mon-Fri 8:00 am to 5:00 pm
Saturday Closed
Sunday Closed