Patient Demographics

Patient Demographics

Name: ______Gender: O Male O Female

FirstMiddleLast

Address: ______City: ______State: ______Zip: ______

Home Phone: ______Cell: ______Work: ______Preferred: O Home OCell O Work

Email: ______Marital Status: O Single O Married O Separated O Divorced O Widowed

Date of Birth: ______Social Security #: ______Language: OEnglish OSpanish O Other: ______

Ethnicity:O Hispanic/Latino O Non Hispanic/Latino Race: O African American O Caucasian O Asian O Hispanic OOther

______

Emergency Contact:

Name: ______Relationship: ______Phone Number: ______

______

Medical Care Providers:

Referring Provider: ______Primary Care Provider: ______

______

Insurance Information:

Primary Insurance: ______Policy ID #: ______Insurance Group #: ______

Secondary Insurance: ______Policy ID #: ______Insurance Group #: ______

Please complete the following if insured person is different than the patient

Relationship to Patient: O Spouse OOther: ______

Insured Name: ______

FirstMiddle Last

Date of Birth: ______Social Security #: ______

Address: ______City: ______State: ______Zip: ______

Home Phone: ______Cell: ______Work: ______Preferred Contact: O Home O Cell O Work

I request that direct payment of authorized Medicare and/or commercial insurance benefits be made to Regional Medical Oncology Center, and the deductible and copayment balances will be paid by the patient and/or guarantor. I further authorize the release of medical information to my physician(s) or my insurance companies that may be pertinent to my care.

______

SignatureDate

Financial Policy

Thank you for choosing Regional Medical Oncology Center (RMOC). Our main concern is that you receive the proper and optimal treatment needed to restore your health.

So that we may better serve you, we ask you to please read, sign, and return this form to us prior to treatment. If you have any questions or concerns regarding our payment policies, please do not hesitate to discuss them with us.

Co-payments for office services are required at the time of registration.
We accept cash, checks, debit cards, Visa, MasterCard, and Discover. A $35.00 fee will be charged for returned checks.
As a courtesy, we will process and file your insurance claims for you.
In addition to co-payments, any unmet deductible or co-insurance of services will be paid each visit, unless payment arrangements have been made. A billing associate is available at any time to discuss payment plan options.
If the patient is a minor (18 years and younger), the parent or guardian is responsible for payment of the account, in accordance with the policies outlined herein.

I certify that I have read and understand the “Financial Policies” and agree to all terms and conditions as stated above. I understand that it is my sole responsibility to verify insurance coverage and I am ultimately responsible for payment in full for any outstanding balances. I understand that the information that I have given today is correct to the best of my knowledge. I also understand that it is my responsibility to inform RMOC of any changes associated with my insurance status. Even though I may have health insurance coverage, I understand payment for services is ultimately my responsibility. I understand that payment for services is due at the time that service is rendered unless other financial arrangements have been made.Initial Here: ______
I hereby guarantee payment of all charges incurred at RMOC. I hereby assign and direct to pay any and all benefits for medical services under this claim to RMOC. I authorize the release of any medical information necessary to process my claim with the above assignment. I also authorize RMOC to file an appeal on my behalf in the event of a claim denial. Initial Here: ______

______

Signature of Patient/Responsible PartyDate

Medicare Patients Only:

We are participating providers of the Medicare program. We will accept assignment on all claims. Patients are responsible for meeting their annual deductible and paying for the 20% co-insurance, if there is no secondary insurance.

I authorize assignment of Medicare benefits to RMOC for any services furnished by that physician/provider. I understand my signature authorizes release of medical information necessary to pay the claim.

______

Signature of Patient/Responsible PartyDate

HIPAACONSENT

TO THE USE AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT OR HEALTHCARE OPERATIONS

I ______understand that as part of my healthcare, Regional Medical Oncology Center originates and maintains paper and / or electronic records describing my health history, symptoms, examination and test results, diagnosis, treatment, and any plans for future care or treatment. I understand that this information serves as:

A basis for planning my care and treatment
A means of communication among the many health professionals who contribute to my care
A source of information for applying my diagnosis and surgical information to my bill
A means by which a third-party payer can verify that services billed were actually provided and
A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals.

I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:

The right to review the notice prior to signing this consent
The right to object to the use of my health information for directory purposes, and
The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations.

I understand that Regional Medical Oncology Center is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I also understand that by refusing to sign this consent, this organization may refuse to treat me as permitted by section 164.506 of the Code of Federal Regulations.

I further understand that Regional Medical Oncology Center reserves the right to change their notice and practices and prior to implementation, in accordance with section 164.520 of the Code of Federal Regulations. Should Regional Medical Oncology Center change their notice, they will send me a copy of any revised notice to the address I’ve provided (whether US Mail or if I agree Email).

O Please do not mail my clinical summary by US Mail. I will obtain this information from the patient portal.

O Please allow the following individuals access to my health information via the patient portal.

I wish to allow the following individuals access to my Health Information:

Name:______Relationship______Contact #______

I understand that as part of this organization’s treatment, payment, or healthcare operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for there permitted uses, including disclosures via fax.

I fully understand and accept / decline the terms of this consent.

______

Patient Signature Date

Patient Chart ID: ______Patient Date of Birth:______

Meaningful Use Questionnaire

Name: ______Date of Birth: ______

Email: ______You will be provided a link to our patient portal.

Marital Status: O Single O Married O Separated O Divorced O Widowed

Occupation: ______ORetired O Disabled

Mother O Living O Deceased Medical History: ______

Father O Living O Deceased Medical History: ______

______What pharmacy do you use?

Pharmacy: ______Location: ______

I, ______, grant Regional Medical Oncology Center permission to electronically download my medication history from my pharmacy.

Signature: ______Date:______

______Please list any known allergies:

Allergies: ______

______When did you last receive the following?

Flu Shot O Yes O No Pneumovac O Yes O No Shingles VaccineO Yes O No

Colonoscopy O Yes O No Date: ______Where? ______

Bone Density Test O Yes O No Date: ______Where? ______

(Female Only)

Last Pap SmearDate: ______Where? ______HysterectomyO Yes O No

Last Mammogram Date:______Where? ______

Monthly Self Breast Exams O Yes O No

(Male Only)

Prostate Exam O Yes O No Date: ______Where? ______

Prostate Specific Antigen (Lab test) O Yes O No Date: ______Where? ____________Smoking Status: O Non-smoker O Current smoker ____packs/day O Former Smoker ____packs/day

Do you use Alcohol? O Never OSocial O Current ____drinks/day O Former ____drinks/day