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Appointments: (602) 889-9401Fax: (602) 889-9404
Equality Care Center
Equality Care CenterEquality Care Center
  • SERVICES
    • Primary Care
    • Pain Management
  • PATIENT FORMS
  • ABOUT US
    • About Equality Care Center
    • Accepted Insurance
  • MEET THE TEAM
  • CONTACT US
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  • SERVICES
    • Primary Care
    • Pain Management
  • PATIENT FORMS
  • ABOUT US
    • About Equality Care Center
    • Accepted Insurance
  • MEET THE TEAM
  • CONTACT US

Patient Forms

By completing your paperwork before you get to the office you save time, and you can see the provider faster.

Patient History Forms

  • Patient Insurance and Information (English)
  • ECC New Patient History EN (English)
  • Informacion de Paciente Y Aseguranza (Español)
  • Historial De Nuevo Paciente (Español)

Consent Forms

  • Consent to Treat a Minor
  • HIPAA – Patient’s Rights
  • Advance Directives (English)
  • Release of Medical Information
  • Autorización Para Prooporcionar Tratamiento Médicoo (Español)
  • Declaración de Voluntad Anticipada (Español)

Financial Forms

  • Office Financial Policy and Waiver (English)
  • Oficina/Política Financiera Y De Exención (Español)
  • HRSA Sliding fee application
  • Sliding Fee Discount Program
Equality Care Center Logo
  • Phone: (602) 889-9401
  • Fax: (602) 889-9404
  • 3306 W. Roosevelt St., Phoenix, AZ 85009
Services
  • Primary Care
  • Pain Management
  • Substance Abuse
  • Telehealth/Virtual Visits
Resources
  • Patient Forms
  • About Us
  • Meet the Team
  • Contact Us
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