EOCC Patient Intake Form

DateTime
Name*

First NameLast Name
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender*
Date of Birth*

MonthDayYear
Date
Age*
Cell Phone*
Work Phone
Are you pregnant or do you want to have more children?*

YesNo
Emergency Contact*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Did you know there was a cancer center in Pendleton before you were referred?*

YesNo
Where else have you heard about Eastern Oregon Cancer Center at Pendleton (check all that apply)*

FacebookGoogleRadio AdsOur WebsitePrint AdvertisementsBillboardHave not seen anywhere elseOther
Preferred Pharmacy*
Preferred Lab*
Providers

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

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

	Medication/Supplement and dose	Times Per Day	Reason for taking
1
2
3
4
5
6
7

Add any medications that did not fit in the table above
Do you have any allergies?*

	Your Cigarette History
Packs/Day
Age at start
Age at stop

	Number
Age of Menopause
Number of Pregnancies
Age of first pregnancy
Number of live births

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.
Uses and Disclosures
Treatment. Your health information may be used by our staff members or disclosed to other healthcare professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of tests and procedures will be available in your medical record for all health professionals who may provide treatment or who may be consulted by our staff members.

Payment. Your health information may be used to see payment from your health insurance plan, from other sources of coverage, or from credit card companies that you may use for payment of services. For example, your health plan may request and receive information on dates of service, the services
provided, and the medical condition being treated.

Health Care Operations. Your health information may be used as necessary to support
the day-to-day activities and management of Eastern Oregon Cancer Center at Pendleton. For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality.

Public Health Reporting. Your information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state’s public health department.

Other uses and disclosures require your authorization. Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing disclosure of your information, you may submit a written revocation of the authorization.
However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred prior to the notification of your decision to us.

Appointment reminders. Your health information may be used by our staff to send you appointment reminders.

Individual Rights

You have certain rights under the federal privacy standards. These include:
• The right to request instructions on the use and disclosure of your protected health
information
• The right to receive confidential communications concerning your medical condition
and treatment
• The right to inspect and copy your protected health information
• The right to amend and or submit corrections to our protected health information
• The right to receive an accounting of how and to whom your protected health
information has been disclosed
• The right to receive a printed copy of this notice

Eastern Oregon Cancer Center’s Duties:

We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices.

We are also required to abide by the privacy privileges and practices that are outlined in this notice.

Right to Revise Privacy Practices

As permitted by law, we reserve the right to amend or modify our privacy practices. These changes in our policy and practices may be required in federal and state laws and regulations. Whatever the reason for the revisions, we will provide you with a revised notice on your next office visit. The revised policies and practices will be applied to all protected health information that we maintain.

Requests to Inspect Protected Health Information
As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records by contacting our front office coordinator.

Complaints
If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concern to the contact person listed below.

If you believe that your privacy rights have been violated, you should call the matter to the attention by sending a letter describing the cause of your concern to the same address.

You will not be penalized or otherwise retaliated for filing a complaint.

Contact Person
The name and address of the person that you may contact for further information concerning our privacy practice is:

Privacy Officer
Eastern Oregon Cancer Center
1713 SW 24ᵗʰ Street
Pendleton, OR 97801

Your signature is an acknowledgment of receipt of
Privacy Practices. If you request a copy of your notice, it will be provided.
Signature*

Clear

Authorizations for Release of Health Information

Unless you specifically agree, we will not disclose any information to family or other persons involved in your care either by phone or in person. This means, for example, that we will not be able to answer questions about your radiation treatments, medications, prescriptions, billing, schedule appointments or otherwise discuss any aspect of your care or treatment with anyone other than you.

If you would like us to be able to discuss information related to your care with specific persons, please list those persons below.*

	Name	Relationship to Patient
1
2
3
4
5
6
7
8
9

I hereby authorize Eastern Oregon Cancer Center at Pendleton to discuss all aspects of my treatments with the above-listed persons.
Signature*

Clear

Patient Financial Responsibility Agreement
At Eastern Oregon Cancer Center, 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 541-304-2264.
•If you do not have insurance, payment of 50% of the estimated treatment costs will be required before treatment starts. The front office coordinator will provide an estimate and payment option for you.
•You are responsible for obtaining any necessary referrals from your primary care physician and prior approval before the start of treatment if required by your insurance company. Please speak to the front office coordinator or contact our business office at 866-353-0360 if you need assistance.
•You are personally responsible to us for the full payment of all services you receive from us. All co-payments and/or deductibles for our services are due at the time of service. 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. We accept 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 a 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 includes reasonable attorneys’ fees and collection costs. If we eventually receive 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 any and 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.
Signature*

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

	Yes	Type of Cancer
Mother
Father
Sister
Brother
Children
Maternal Grandmother
Grandfather
Aunt
Uncle
Paternal Grandmother
Grandfather
Aunt
Uncle
None

	Yes	No	N/A
Do you have an Advance Directive?
Do you have a Do Not Resuscitate/Do Not Intubate Directive?
If yes, would you provide us with a copy for your medical records?
If you do not have an advance directive, would you like information?

Providers

Social History

Current Symptoms

HIPAA Notice of Privacy Practices

Authorizations for Release of Health Information

Patient Financial Responsibility Agreement

	Allergy	Allergic Reaction
1
2
3
4
5

	Past Medical History	Year of Diagnosis
1
2
3
4
5
6

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