PROC Patient Intake Form

DateTime
Who is completing this form*
Name*

First NameLast Name
Email*
example@example.com
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different from physical)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender*
Do you consent to receive text appointment reminders & information about your health care treatment?*

YN
Date of Birth*

MonthDayYear
Date
Age*
Cell Phone*
Work Phone
Emergency Contact*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Did you know Peninsula Radiation Oncology Center was in Soldotna before you were referred?*

YesNo
Where else have you heard about Peninsula Radiation Oncology Center (check all that apply)*

FacebookGoogleRadio AdsOur WebsiteNewspaperFriend/Family MemberHave not seen anywhere elseOther
Providers

Please indicate your providers below:
Referring Physician
Primary Care Physician
Medical Oncologist
Surgeon
Other Provider
Other Provider

Medications (put N/A in the first cell if no medication)*

	Medications	Dose	Times per day
1
2
3
4
5

Do you have any allergies?*

Allergy to Medications or IV Contrast*

	Yes or No	Explain
Medications
IV Contrast

	Your Cigarette History
Type of Cigarettes
Packs/Day
# of years
Age at start
Age at stop

HIPAA Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I authorize you to give me reasonable and proper medical care by today’s standards. All professional services rendered are charged to the patient, and necessary forms will be completed to help expedite insurance carrier payments. However, the patient is responsible for fees, regardless of insurance coverage. It is also customary to pay for services when rendered unless other arrangements have been made in advance with Peninsula Radiation Oncology Center.

I request payment of authorized Medicare/Other Insurance company benefits be made on my behalf to Peninsula Radiation Oncology Center, for any services furnished me by that party who accepts assignment/physician. Regulations pertaining to Medicare assignment of benefits apply.

I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carrier or any other insurance company any information needed for this or a related Medicare/Other Insurance company claim.

I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. In Medicare /Other Insurance Company assigned cases, the physician agrees to accept the charge determination of the Medicare/Other Insurance Company as the full charge, and the patient is responsible only for the deductible coinsurance, and non-covered services. Coinsurance and the deductible are based upon the charge determination of the Insurance Company.
Receipt of HIPAA Information

We are required by law to maintain the privacy of and provide individuals with this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer at (907) 262-7762. Signature below is acknowledgement that you have received this Notice of our Privacy Practices.
Signature*

Clear
Legal Representation

First NameLast Name
Legal Representation Relationship

Care Consent & Financial Policy
I authorize you to give me reasonable and proper medical care by today’s standards. All professional services rendered are charged to the patient, and necessary forms will be completed to help expedite insurance carrier payments. However, the patient is responsible for fees, regardless of insurance coverage. It is also customary to pay for services when rendered unless other arrangements have been made in advance with Peninsula Radiation Oncology Center.

I request payment of authorized Medicare/Other Insurance company benefits be made on my behalf to Peninsula Radiation Oncology Center, for any services furnished me by that party who accepts assignment/physician. Regulations pertaining to Medicare assignment of benefits apply.

I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carrier or any other insurance company any information needed for this or a related Medicare/Other Insurance company claim.

I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. In Medicare /Other Insurance Company assigned cases, the physician agrees to accept the charge determination of the Medicare/Other Insurance Company as the full charge, and the patient is responsible only for the deductible coinsurance, and non-covered services. Coinsurance and the deductible are based upon the charge determination of the Insurance Company.
Signature*

Clear
Please verify that you are human*
Should be Empty:

Providers

Medical History

Social History

Current Symptoms

HIPAA Notice of Privacy Practices

Receipt of HIPAA Information

Authorizations for Release of Health Information

Care Consent & Financial Policy

	Allergy	Allergic Reaction
1
2
3

	Type/Reason	Date (MM/YY)	Location/Facility
1
2
3
4

	Relative with History of Cancer (Relationship)	Type of Cancer	Age of Diagnosis
1
2
3

	Name	Relationship to Patient	Phone Number	Care	Medical Records	Financial	Billing
1
2
3
4
5