NEOK Patient Intake Form Logo

  • Radiation Oncology New Patient Information

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  • Emergency Contacts:

  • In accordance with the Health Insurance Portability and Accountability Act (HIPAA), I agree that Northeastern Oklahoma Cancer Institute and its authorized agents and employees may disclose protected health information directly relevant to involvement with my care, or payment related to my care, to my emergency contacts, who may contact Northeastern Oklahoma Cancer Institute on my behalf.

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  • Please answer the following questions to the best of your ability. If you have a problem completing any section, please ask your doctor for an explanation.

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  • Have you RECENTLY experienced any of the following?

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  • Have you EVER experienced any of the following?

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  •  Patient Financial Responsibility Agreement

    At Northeastern Oklahoma Cancer Institute, we truly appreciate the opportunity to provide you with compassionate, state-of-the-art care.  This Agreement identifies your financial obligations for all the services you receive from us, including the services provided today and in the future.  Please let us know if you do not understand any of the items discussed in this agreement.

    • Please inform us of ALL insurance coverage you possess, and of any recent changes.  This is crucial for proper billing and to ensure insurance coverage for our services, when available.  We need correct and current information on a timely basis.  If your insurance coverage changes, please contact our office immediately at 918-283-4078.
    • If you do not have insurance, a payment plan can be established via our business office.
    • At your request, a financial counselor can provide you with an estimate of your financial responsibility for your treatment.  However, please understand that an estimate is not binding and that the actual cost may be different. You are personally responsible to us for the full payment of all services you receive from us. Our business office accepts payment for daily co-pays via cash, check, or credit card.
    • We will submit a claim to your primary and secondary insurance for all services that we provide to you.  If we do not receive payment within 30 days of submission or your insurance notifies us that you are not covered under your insurance plan (e.g. the services were not pre-authorized), you will pay us the outstanding balance of the services.  We will send you a statement for the amount due.  If your account, including reasonable attorneys’ fees and collection costs.  If we eventually receive a payment from your primary or secondary insurance, we will refund the difference to you.
    • You authorize and direct any insurance proceeds payable for services provided by us to you to be paid directly to us, and assign to us, without recourse, all interest in and rights to claim, collect and receive the proceeds from any insurance company providing coverage for our services.  You authorize any insurance company to furnish to use and our agents all information pertaining to your insurance benefits and the status of all claims submitted by us.
    • We are Medicare providers and accept assignments from Medicare.  However, there may be a balance due from you after Medicare pays.  Medicare law prohibits us from waiving this balance.

     

    I have read this Agreement, understand its content, and agree to its provisions.

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  • Authorization to Obtain Medical Records

    By signing and dating the fields below you authorize us to obtain medical records as it pertains to your care in our center. 

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