Phoenix CyberKnife Patient Forms

7/28/2019 Phoenix CyberKnife Patient Forms

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4611ESheaBlvd,Suite120,Phoenix,AZ85028Tel:602-441-3845Fax:602-646-9769 www.phoenixcyberknife.comwww.roca-med.com

Phoenix

CYBERKNIFEAndradiationoncologycenter

Pag

Thank you for choosing Phoenix Cyberknife and Radiation Oncology.

In an effort to make your initial visit both pleasant and efficient, we have several patient information forms to be completed before your

appointment. This information will be used to prepare your medical chart.

Please complete these forms and bring them with you 30 minutes prior to your appointment, or you may fax or mail the completedforms to our office prior to your appointment. When you arrive, we will photocopy your insurance card and drivers license. If you have

a copy of your medical records and or radiology scans on CD, you are welcome to mail, fax or bring them by our office, as our

providers like to review your history 1 to 2 days prior to your appointment. Also note that some of the paperwork will be for John C.

Lincoln Hospital, these forms are for billing purposes for your treatment.

If your insurance company requires a referral or authorization number for you to see a specialist, please contact your primary care

physician for the necessary referral or authorization number. Any co-payments for the initial consultation are payable at the time of

service. We accept cash, check or credit cards.

A nurse will be seeing you prior to your visit with the physician. At that time she will go over your medications and medical history, so

please bring your medications and a list of any physicians currently involved in your care.

If you have any questions or need assistance, please feel free to call our office between 8:00am and 5:00pm, Monday through Friday.

On behalf of Phoenix Cyberknife and Radiation Oncology, we look forward to meeting you and helping you with your medical needs.

Sincerely,

Your Phoenix Cyberknife and Radiation Oncology Team

Phone 602-441-3845

Fax 602-464-9769


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PATIENT PERSONAL INFORMATION

Name : __________________________________ DOB: ____________________ Sex: _______

Race: ________________________ Preferred Language: ________________________________

Ethnicity (circle one): Hispanic/Latino Non-Hispanic/Non-Latino Unwilling to Provide Unknown

Address:____________________________________________________________________________________________________________________________________________________________________________________________________Marital Status: Married Single Divorced Widowed Domestic PartnershipSocial Security #: ____________________________________________

Employer _________________________________________ Occupation __________________Street Address: _________________________________________________________________City: ____________________________State: ____________________ Zip: ________________

RESPONSIBLE PARTY INFORMATION Information Same as AboveResponsible Party ________________________________________ DOB _____/_____/____Relationship to Patient SelfSpouse Other ____________ SSN _____-_____-_____Street Address _________________________________________ Apt #_______City ______________ State _____ Zip _________Home Phone (_________) _______-__________ Cell Phone (_________) _________-________Work Phone ( _______ ) ________-________Employer _________________________________________ Occupation _______________

PATIENT INSURANCE INFORMATION Please present insurance card at check-in

Name of Insured ______________________________________________________________

Primary Insurance Company__________________________________________________Patient relationship to Insured Self Spouse Other ____________________Insurance ID _____________________________ Group # _________________________

Secondary Insurance Company_______________________________________________Patient relationship to Insured Self Spouse Other ___________________Insurance ID _____________________________ Group # _________________________

EMERGENCY CONTACT

Name ____________________________________ Relationship _____________________________Address___________________________________________________________________________

Street, City, State, ZipHome Phone: ___________________ Cell Phone: __________________ Work Phone: _________________

Are we able to discuss your medical information with your emergency contact: ___ Yes ___No


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I have received a copy of the Privacy Rules from this practice

Signature: ________________________________________________Date: __________________________

How were you referred you to our office?

Please check one: Previous patient of our office:_________________________________ Facebook/LinkedIn Insurance Provider Friend/Family Directory Billboard TV/Commercial Magazine/ Newspaper Website/Internet Physician (Name): _____________________________________ Other _________________________


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PatientName:____________________________________________

DOB:___________________________________

CONSENTTOCOMMUNICATE

Pleasemarkthewaysthatyouconsentustocommunicatewithyou.

Methodof

Communication

PhoneNumber Preferred

Methodof

Contact

OKtoleavea

Message

OKtoleavea

messagewith

anotherperson

HomePhone YES NO YES NO

CellPhone YES NO YES NO

WorkPhone YES NO YES NO

IfitsOKtoleaveamessagewithanotherperson,pleaselistthem

NAME Relationship OKtoReleaseTestResults

YES NO

YES NO

UseofText:

TextMessagesforApptReminders YES NO IfYes:CarrierName:

Email:

EmailApptReminders YES NO IfYestoany,pleaseaddaddressbelow:

EmailMedicalInfo YES NO

IunderstandthatIamallowingpersonalandmedicalnecessitycommunicationintheabovestated

methods.Ihavetherighttochangemymindatanytimebyrequestinganewcommunicationconsent

form.Itwillbemyresponsibilitytoalwaysensuremyphonenumbersandemailaddress(es)arecorrect

andIwillnotifyPCROCofanychanges.

PatientSignature:_________________________________________________Date:___________________


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PHYSICIAN LIST

Name : __________________________________________ DOB: ______________________

To help us ensure continuity of care, please provide us with the following list of all doctors involved in your care. If at any time, you

add, change or drop a physician please let our office know so that we may continue to keep the proper doctors informed. Thank You.

OTHERs NOT LISTED

Specialty: _____________________________________Name: _______________________________________________

Phone#: ______________________________Address:______________________________________________________

__________________________________________________________________________________________________

Specialty: _____________________________________Name: _______________________________________________

Phone#: ______________________________Address:________________________________________________________________________________________________________________________________________________________

Specialty: _____________________________________Name: _______________________________________________

Phone#: ______________________________Address:______________________________________________________

__________________________________________________________________________________________________

Name of Pharmacy: ______________________________ Phone # (______) ________________Location: Major Cross Road __________________________________________


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REVIEW OF SYSTEMS WORKSHEET

Name : __________________________________________ DOB: ______________________ Age: ________

Brief Explanation for Todays Visit:

____________________________________________________________________________________________________________________________________________________________________________________________________________

Past Medical History:Have you had radiation treatment in the past? Yes NoTo what part of body? ___________________________________________________________When: ___/___/___ Facility: ______________________________________________________Have you had chemotherapy in the past? Yes NoWhen: ___/___/___ Facility: _____________________________________________________Are you currently undergoing chemotherapy? Yes NoDate of last dose: ___/___/___ Facility: ____________________________________________

Any previous surgeries: Yes NoType: Date: Facility: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Implanted Devices: Do you have any implanted or metal devices? Yes NoVenous Access Device/Type___________________ PacemakerAneurysm ClipScrews, pins, plates/Where? ___________________ Stent Other______________

Do you have? Diabetes Thyroid Problems Other:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Smoking History:Have you ever smoked? Yes No (If yes please answer the following questions)Do you currently smoke? Yes No # of Packs per Day: _________ Number of years: _________If you have quit smoking: When: _____/_____/______

Alcohol Consumption:Do you consume alcohol? Yes NoIf yes: How often? _________________________ How much? ______________________

Gynecological: (Females Only)# of Children: _____ # of Pregnancies: _____ # of l ive births: ______ Other: ____________How old were you when your 1st child was born? _____________Did you breastfeed? Yes No How Long? ______________Age at 1st Menstrual Period: _____ Last Menstrual Period: ___/___/___Last Pelvic Exam/PAP: ___/___/___


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Hormones: Yes No Name: _____________________ How Long? ______________Hysterectomy: Yes No When: ___/___/___ Why? ______________________________Do you do self breast exams? Yes No How often? ________________________Date of last menstrual period: ____/_____/_____Type of birth control currently used: __________________________Date of last mammogram: _____/_____/_____ Facility: ______________________________________

Family History:Is there any family history of cancer? (If yes; Who? And what type of cancer?)__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Allergies: None IV Contrast Reaction: __________________ Iodine Reaction: __________________Latex Reaction: __________________ Sulfa Reaction: _________________

Penicillin Reaction: __________________ Codeine Reaction: __________________Other/ Reaction_______________________________________________________________________

Weight: _______lbs. Height: _____ft._____in

Please provide us with a list of current medications:

Medication Dosage Frequency Purpose of Medication

***If you need more space, please use reverse side***

Review of Systems: (please check all that apply to your health)

General:Please rate your level of fatigue 0-10 (0=none, 10=severe): _________Are you now experiencing pain? Yes No - If so, where? _________________________Please rate your pain level 0-10 (0=none, 10=severe): _________Do you experience any of the following?


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Fever Chills Night Sweats Sleep ProblemsPlease explain: _________________________________________________________________

Skin: No problems

Rashes Itching Skin Cancers Burn easily in sun Other__________________________________________

Heart: No Problems Blood Pressure Problems Bruising/Bleeding Palpitations Swollen Ankles Heart Attack/when? ___/___/___ Other_________________________________

Neurological: No Problems Memory Loss/Forgetfulness Fainting Spells/Dizziness Visual Complaints Claustrophobia Seizures/Convulsions Headaches/Migraine History Hearing Complaints Stroke Other ______________________________________

Respiratory: No Problems Shortness of Breath: At Rest With Activity Home Oxygen (LPM_____) Hoarseness Breathing Medications Asthma Other:__________________________Do you have a cough? Yes No If yes, does it produce: Blood or Phlegm?

Skeletal/Muscular: No Problems

Arthritis Numbness/Tingling Weakness/Balance Problems Back/Neck Pain Blood Clots: Where? _____________________________________ Collagen Vascular Disease (i.e. Lupus, Scleroderma, etc.)

Digestive:Appetite: Good Fair PoorWeight Loss: Have you lost weight in the last 6 months? Yes No How much: ____________ No Problems Nausea/Vomiting Heartburn/Reflux Ulcers/Hiatal Hernia Swallowing Problems Sores in Mouth Chewing Problems Dentures Other_________________________________________________________________

Do you follow a special diet? (If so, please explain) _______________________________________

Date of last Colonoscopy: ______________________________________________

Urinary No Problems Burning Frequent Discomfort Catheter Ostomy Urinary Tract Infections Incontinence (unable to hold bladder) Other_______________________________________________


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Bowel No Problems Diarrhea Constipation Stool Incontinence (loss of control) Ostomy Liver Disease/Hepatitis Other______________________________________________________Last BM:______________ Frequency of BM: _________________

If you have further information, which you feel would allow us to provide you with better care, or have special needs thatmust be addressed, please write it in the space below.______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


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AssignmentofInsuranceBenefits

IherebyauthorizepaymenttoRadiationOncologistsofCentralArizona,PhoenixCyberknifeandradiationOncologyCenterandto

thephysician(s)andspecialistphysician(s)involvedinmytreatment.Theinsurancebenefitsspecifiedonmyadmissionformandfor

otherinsurancecarriers,otherwisepayabletomebutnottoexceedthebalanceduefortheregularchargesfortheperiodof

treatments.

InsuranceAssignmentandRelease

I,theundersignedcertifythatIhaveinsurancecoveragewithandassigndirectlytoRadiationOncologistsofCentralArizona,

PhoenixCyberknifeandradiationOncologyCenter,andotherphysiciansrelatedtomycourseoftreatment,allinsurancebenefits,if

any,otherwisepayabletomeforservicesrendered.IunderstandthatIamfinanciallyresponsibleforallchargeswhetherornotpaid

byinsurance.IherebyexpresslyguaranteepaymentinfullofanyandallchargesinconsiderationformedicalservicesrenderedI

herebyauthorizethedoctortoreleaseallinformationnecessarytosecurethepaymentofbenefits.Iauthorizetheuseofthis

Signatureonallinsurancesubmissions.

MedicareAuthorization

IcertifythattheinformationgivenbymeinapplyingforpaymentundertheTitleXVIIIoftheSocialSecurityActiscorrect.I

authorizeanyholderofmedicalorotherinformationaboutmetoreleasetotheSocialSecurityAdministrationandCMSorits

MedicarecontractorsanyinformationneededforthisorarelatedMedicareclaim.Irequestthatpaymentofauthorizedbenefitsbe

madeonmybehalf.Iassignthebenefitspayableforphysicianservicestothephysicianororganizationfurnishingtheservicesor

authorizedsuchphysicianororganizationtosubmitaclaimtoMedicareforpaymenttome.IunderstandIamresponsibleforanyhealthinsurancedeductibleandCoinsuranceamountswhereapplicable.

AuthorizationofreleaseofInformationforInsuranceBenefits

IherebyauthorizeanddirectRadiationOncologistsofCentralArizona,PhoenixCyberknifeandRadiationOncologyCenter,andthe

Physicianshavingtreatedme,toreleasetogovernmentalagencies,InsuranceCarriersorotherswhoarefinanciallyliableformy

hospitalizationandmedicalcareallinformationneededtosubstantiatepaymentsforsuchhospitalizationandmedicalcareandto

permitrepresentativesthereoftoexamineandmakecopiesofIIrecordsrelatedtosuchtreatment.

AuthorizationforAppeal

TheFederal/Stategovernmentandthirdpartyinsurersoftenrequirethatapatient'smedicaltreatmentbejustifiedbyareview

organization.Whereaclaimforpaymentisdeniedbythereviewingorganization,itbecomesnecessaryfortheclinicaltoaskfor

reconsiderationandsometimestomakeanappealtoagovernmentagencyorthirdpartyinsureronyourbehalf.Toenableusto

takethesestepstoobtainpaymentofyourmedicalbill,weaskthatyoupleasesigntheauthorizationbelow.Iherebyauthorize

RadiationOncologistsofCentralArizona,PhoenixCyberknifeandRadiationOncologyCenter,andotherphysiciansrelatedtomy

treatmenttotakeallnecessarystepsonmybehalftoseekreconsiderationand,ifnecessary,anappealtotheappropriateagency

havingjurisdiction,ofanyadversedeterminationwhichaffectstheallowanceofMedicare,MedicaidBlueCrossorotherCommercia

InsurancereimbursementrelatingtoRadiationOncologistsofCentralArizona,PhoenixCyberknifeandRadiationOncologyCenter,

andotherphysiciansrelatedtomytreatment.

FinancialAgreement

ForandinconsiderationofservicesrenderedortoberenderedbyRadiationOncologistsofCentralArizona,PhoenixCyberknifeand

RadiationOncologyCenter,andotherphysiciansrelatedtomytreatmenttothepatientwhosenameappearsabove,the,"

undersigned(jointlyandseverallyifmorethanthatone)herebyagree(s)tobefullyandtotallyresponsibletoRadiationOncologists

ofCentralArizona,PhoenixCyberknifeandRadiationOncologyCenter,andotherphysiciansrelatedtomytreatmentforpaymentI

allchargesassubmittedbythecliniconaccountofthepatientandtomakepaymentinaccordancewhthepolicyforpaymentofbillsattheclinic.Itisfurtheragreedthatthechargesincurredrepresentsthefairandreasonablevalueoftheservicesrenderedand

areinaccordancewiththepostedchargesoftheclinicwhichareavailableuponrequest.Paymentmaybedemandedatanytime

andthedemandforpaymentofthepatientshallbeaprerequisitetomy(our)immediateresponsibilityforpayment.

Patient,responsibleparty(ies),orauthorizedagent Date

Witness Date


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Name : __________________________________________ DOB: ______________________

InsuranceandBillingPolicy

Ourpolicyistobillthepatientafterinsurancehashadtheopportunitytoconsiderthecharges.PatientswhoareselfpayareresponsiblefortheentirebalanceforallservicesrenderedbythephysiciansofRadiationOncologistsofCentra

ArizonaandPhoenixCyberknifeandRadiationOncologyCenter.

Please advise our office if there are any changes in your insurance information you are accountable and could be

responsibleforthefullbalance.Shouldyouhaveanyquestionsconcerningyouraccount,orifyouwishtospeaktoyou

accountmanager,pleasecall800-228-3565,extension5813betweenthehoursof8:30amand5:00PMEST,Monday

throughFriday.

I authorize Radiation Oncologists of Central Arizona, Phoenix Cyberknife andRadiation Oncology Center, and othe

physician(s) related tomy treatment to bill my insurance company for charges incurred during the course of my

treatment,andtoprovideanymedicalinformationnecessarytoprocessthisclaim.Iunderstandthattheremaybe

additionalchargesforthesurgeonthatparticipatedinthetreatmentplanningprocessandtherewillbeabillsenttome

separatelyby them. I authorizepayment tobemade directly toRadiationOncologistsofCentralArizona,Phoenix

Cyberknife andRadiationOncologyCenter, andotherphysicians relatedtomycourseof therapyanda copy of thi

authorizationmaybeused insteadof theoriginal. I authorize RadiationOncologistsofCentralArizonaandPhoenix

CyberknifeandRadiationOncologyCenterandotherphysician(s)relatedtomytreatmenttoinquireaboutmyaccount

andtoreceiveanyinformationaboutanyandallofmyMedicare,BlueShieldorotherinsuranceclaims,assignedornon

assignedandIunderstandthatIamfullyresponsibleforchargesincurredwiththetreatmenteventhoughthedoctor

files my insurance for me. I understand that delinquent accounts are subject to collection and acknowledge

responsibility.

Ihavereadandunderstandtheaboveinsuranceandbillingpolicy.

_____________________________________________ ____________________________

Patientorresponsibleparty(ies)Signature Date

__________________________________________ ____________________________

Witness Date


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TOBECOMPLETEDBYMEDICARECOVEREDPATIENTSONLY

Date:_______________________

PersonProvidingInformation:__________________________________________________

Howwasinformationobtained:InpersonTelephoneFax(PleaseCircle)

1. AreyoureceivingBlackLung(BL)Benefits?Yes No (PleaseCircle)Ifyes,datebenefitsbegan_______________________

2. Aretheservicestobepaidbyagovernmentresearchprogram?YesNo(PleaseCircle)

3. HastheDepartmentofVeteransAffairs(DVA)authorized&agreedtopayforcareatthisfacility?YesNo(PleaseCircle)

4. Wasillness/injuryduetoaworkrelatedaccident/condition?Yes No (PleaseCircle)Dateofillness/injury:______________ Policyoridentification#:____________________

NameofEmployer:________________________________________________________

EmployerAddress:________________________________________________________

City__________________________________________State_________Zip________

NameofWorkersCompPlan:_______________________________________________

WorkersCompPlanAddress:_______________________________________________

City______________________________State_________Zip________

5. Wasillness/injuryduetoanon-workrelatedaccident?Yes No (PleaseCircle)Ifyes,dateofinjury_______________________

6. Isno-faultInsuranceavailable?YesNo(PleaseCircle)(Nofaultinsuranceisinsurancethatpaysforhealthcareservicesresultingfrominjurytoyouordamagetoyour

propertyregardlessofwhoisatfaultforcausingtheaccident)

NameofPersoninsured:___________________________________________________

DateofAccident:______________InsuranceClaim#:___________________________

NameofNo-faultInsuranceCo:______________________________________________

InsuranceCompanyAddress:_______________________________________________

City__________________________________________State_________Zip________

7. Isliabilityinsuranceavailable?YesNo(PleaseCircle)(Liabilityinsuranceisinsurancethatprotectsagainstclaimsbasedonnegligence,inappropriateactionorinaction,

whichresultsininjurytosomeoneordamagetoproperty)

NameofResponsibleParty:________________________________________________

ResponsiblepartysInsuranceClaim#:_______________________________________

NameofLiabilityInsuranceCo:_____________________________________________


City__________________________________________State_________Zip________


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8. AreyouentitledtoMedicare:YesNo (PleaseCircle)IfYesBasedon:(PleaseCircleonlyonebelow)

AgeDisabilityESRDAge&ESRDDisability&ESRD

9. Areyoucurrentlyemployed?YesNoNever(PleaseCircle)NameofEmployer:________________________________________________________


City__________________________________________State_________Zip________

10. Areyouretired?YesNo (PleaseCircle)Ifyes,dateofretirement_______________________

11. Isyourspousecurrentlyemployed?YesNoNever(PleaseCircle)NameofEmployer:________________________________________________________


City__________________________________________State_________Zip________

12. Isyourspouseretired?YesNo (PleaseCircle)Ifyes,dateofretirement_______________________

13.Doyouhavegrouphealthplan(GHP)coveragebasedonyourown,oraspouses,currentemployment?YesNo(PleaseCircle)

IfYes(PleaseCircleonlyone)Yes-BothYes-SelfonlyYes-Spouseonly

Ifyes,PolicyandgroupID#________________________________________________

NameofInsuranceCompany:_______________________________________________


City__________________________________________State_________Zip________

NameofPolicyHolder:_____________________________________________________

Policyholdersrelationshiptopatient:__________________________________________

14.DoestheemployerthatsponsorsyourGHPemploy20ormoreemployees?YesNo(PleaseCircle)

15.Doyouhavegrouphealthplan(GHP)coveragewithanyotherfamilymembersinsurancecompany?YesNo(PleaseCircle)

Ifyes,PolicyandgroupID#________________________________________________

NameofInsuranceCompany:_______________________________________________


City__________________________________________State_________Zip________

NameofPolicyHolder:_____________________________________________________

Policyholdersrelationshiptopatient:__________________________________________

Nameoffamilymember:____________________________________________________

NameofEmployer:________________________________________________________


City__________________________________________State_________Zip________

16.DoestheemployerthatsponsorsyourGHPemploy100ormoreemployees?YesNo(PleaseCircle)


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17.Haveyoureceivedakidneytransplant?YesNo(PleaseCircle)Ifyes,Dateoftransplant_______________

18.Haveyoureceivedmaintenancedialysistreatments?YesNo(PleaseCircle)Ifyes,Datedialysisbegan:_______________

Ifyouparticipatedinaselfdialysisprogram,providedatethetrainingstarted:__________

Areyouwithinthe30monthcoordinationperiod?YesNo(PleaseCircle)

19. AreyouentitledtoMedicareonthebasisofeitherESRDandageorESRDanddisability?YesNo(PleaseCircle)

20.WasyourinitialentitlementtoMedicare(includingsimultaneousentitlement)basedonESRD?YesNo(PleaseCircle)


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NOTICEOFPRIVACYPOLICYFORPROTECTEDHEALTHINFORMATION(PHI)

TheofficeofPhoenixCyberknifeandRadiationOncologyLLCisdedicatedtoprotectyournonpublicpersonalhealthinformation.

Thisistotellyouhowandwhywecollectthatinformation,andwhohasaccesstothatinformation.

HOWWECOLLECTYOURINFORMATION:

Yourpersonaldemographicinformationsuchasname,address,birthdate,socialsecuritynumber,andmedicalinsurance

informationisobtainedfromyou.Thisiswhyweaskyoutofilloutthepatientinformationsheetandwhyweaskforacopyofyour

insurancecardanddriverslicense.Thisensuresyouthattheinformationwecollectiscorrect.

Ifyoucametoourpracticethroughahospitalencounter,wemayobtaintheinformationfromthehospital.However,onyourfirst

visittothisofficewewillaskyoutofilloutourinformationsheettoinsurethattheinformationwereceivedfromthehospitalwas

correct.

Wemayalsoaskadoctororotherhealthcareproviderwhoreferredyoutothispracticetofiveushealthinformationthatwill

enableustobettertreatyourmedicalcondition.Thisbenefitsyouinthatwewillhavetestresultsthathavealreadybeenobtained

bythereferringentity.

WHYWECOLLECTTHISINFORMATION:

Wecollectthisinformationsothatwecantreatyourmedicalconditionandobtainpaymentfromyouoryourhealthinsurance.

MAINTAININGACCURATEANDTIMELYINFORMATION:

Toinsurethattheinformationwemaintainisaccurate,eachtimeyouvisitthisofficeyouwillbeaskedinanyofyourinformation

needstobeupdated.

WHOHASACCESSTOTHISINFORMATION?

Anypersonorpersonsyoudesignateinwriting,peopledirectlyinvolvedinyourmedicalcare,peoplecreatingandmaintainingyour

medicalrecord,andthoseentitiesthatneedyourinformationtoprocesshealthcareclaimsandobtainpaymentforourservices

haveaccesstoyourProtectedHealthInformation.

EntitiessuchasGovernmentOversightagencies,JudicialandAdministrativeProceedings,LawEnforcementAgencies,Coronersand

MedicalExaminers,andOrganProcurementOrganizationsmayobtaincopiesofyourProtectedHealthInformation.Theseentities

aremandatedbylawandthispracticehasnojurisdictionoversuchentities.

HOWWEPROTECTYOURINFORMATION:

Wereleaseyouronlytothosepeoplewhoneedyourinformation.Wemaintainphysical,electronic,andproceduralsafeguardsso

thatnoonebutpersonsinvolvedinyourhealthcareorentitiesthatneedthisinformationforclaimsprocessinghaveaccesstoyour

ProtectedHealthInformation.

IFyouleavethispractice,yourProtectedHealthInformationwillcontinuetoreceivetheprotectionoutlinedinthisnotice.

COMPLAINTS/COMMENTS: Ifyouhaveanycomplaintsconcerningourprivacypractices,youmaycontacttheprivacyofficerofthis

practiceat602-441-3845.

ThisPracticereservestherighttoamendourprivacypolicyasdictatedbylaw,withoutsendingyouacopyoftheamendment.Any

changestoourpolicywillbepostedinouroffice.ThisnoticeiseffectiveasofFebruary21,2013.


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AUTHORIZATIONTORELEASEPROTECTEDMEDICALINFORMATION

PatientName:___________________________________________DateofBirth:___________________________

BysigningbelowIgivepermissionfortheinstitutionlistedtodisclosemyprotectedhealthinformationtoPhoenixCyberknifeand

RadiationOncologyCenter:

Person/Institution:__________________________________________________________________________________Address:_________________________________________________________________________________________

Phone:______________________________________Fax:___________________________________________

Thisprotectedhealthinformationisbeingusedordisclosedforthefollowingpurpose:

Medicalconsultation,follow-upappointment,and/ortreatment

Informationtobedisclosed Dates(ifknown):_________________________________________

MostRecentHistoryandphysical

Dischargesummary

Initialconsultationnote

MostRecentprogressnote

Allradiologyreportsandimagingdiscsordatesspecified:_____________________AllOperativereportsordatesspecified:______________________

AllPathologyreportsordatesSpecified:______________________

Mostrecentlaboratoryresults

Chemotherapyrecords

Radiationtherapyrecords:InitialConsult,treatmentsummaries,treatmentplans,planimages.

Other________________________________________________________________________________

Datebywhichtheinformationisneeded:_____________________________________________________________

SendRecordsto:

4611ESHEABLVD,SUITE120

PHOENIX,AZ85028P:602-441-3845

F:602-464-9769

Ifthepersonorentityreceivingthisinformationisnotahealthcareproviderorhealthplancoveredbyfederalprivacyregulations,theinformation

describedabovemaybedisclosedtootherindividualsorinstitutionsandnolongerprotectedbytheseregulations.

Youmayrefusetosignthisauthorization.Yourrefusaltosignwillnotaffectyourabilitytoobtaintreatmentorpaymentoryoureligibilityfor

benefits.Youmayinspectorcopytheprotectedhealthinformationtobeusedordisclosedunderthisauthorization.Forprotectedhealth

informationcreatedaspartofaclinicaltrial,yourrighttoaccessissuspendeduntiltheclinicaltrialiscompleted.

YoumayrevokethisauthorizationinwritingatanytimebysendingwrittennotificationtoPhoenixCyberknifeandRadiationOncologyCenter,4611

E.SheaBlvd,Ste120,Phoenix,AZ85028.Yournoticewillnotapplytoactionstakenbytherequestingperson/entitypriortothedatetheyreceive

yourwrittenrequesttorevokeauthorization.

Thisagreementwillexpireoneyearfromthedateofsignatureunlesscancelledbythepatient/guardian.

_________________________________________________________ _________________________________

SignatureofPatient Date

_________________________________________________________ _________________________________

LegalGuardian/PatientRepresentative/RelationshiptopatientDate

Phoenix CyberKnife Patient Forms

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Transcript of Phoenix CyberKnife Patient Forms