Patient Registration Form 

 Patient Name:_________________________________________ Birth Date:____________ Gender: M__ F__ Permanent Address: ____________________________________City:__________________________ State: _____ Zip Code:___________ Home Phone: ___________________ Cell Phone:____________________________ Office may Leave a detailed message: Yes No Email: ______________________________ Marital Status: Single Married Divorced Widow/widower Social Security Number: ________________ Employment Status: Full time Part-Time Unemployed Retired Disabled Race: _______________ Ethnicity: _____________________ Preferred Language: ________________________ Referring Doctor:__________________________ Referring Doctor Phone Number: _____________________________

Insurance Information Primary Insurance: __________________________ Secondary Insurance: _________________________ Policy# / SSN# : ____________________________ Policy# / SSN# : ______________________________ Insurance Address: __________________________ Insurance Address: ____________________________ Policy Holder Name: _________________________ Policy Holder Name: ___________________________ Policy Holder DOB: __________________________ Policy Holder DOB: ____________________________ Relationship to patient: _______________________ Relationship to patient: _________________________

Authorization, Assignment And Release I Authorize Phoenix Cancer Institute to perform evaluation and treatment, as they deem necessary. I further authorize my insurance company to pay Phoenix cancer Institute all medical benefits. I understand that ultimate i am responsible for all charges not covered by my insurance company. I, Also, understand I will be responsible for all collection and legal fees, if my account is placed with an outside collection agency. I hereby Authorize this office to release records pertaining to my treatment to my insurance company or other third parties responsible for payment of my medical charges, including review activities related to my physician’s participation with my health plan. I authorize the use of this signature on all my insurance submissions whether manual or electronic ____________________________________ ______________________ Signature of Insured Date

Patient Name: ___________________________ Date of Birth: ________________ Date:______________

Health History 

ANY Previous Surgical procedures of operations: Yes: ___ No: ____

Date: Type: Facility:

Implanted Devices: Please mark if you have any of the following devices: __ Picc Line / Port __ Pacemaker __ Aneurysm Clip __ Stent __ Screws, pins, plates. If yes, Where? __________________ Other________________________ Are You Claustrophobic? ___ Yes ___ No Do you Have any allergies? (if yes please list allergies and reactions below): _____________________________________________________________________________________ _____________________________________________________________________________________ Current Medications:

Medication Strength Frequency Prescriber Purpose of medication

Medical History: Do you have any other previous or ongoing medical condition? If yes, please list treatment and conditions below. High Blood pressure: __ Yes __ No __________________________________________________________ Heart Disease: __ Yes __ No _______________________________________________________________

Diabetes: __ Yes __ No If Yes, Do you require Insulin? __ Yes __ No Thyroid Dysfunction: __ Yes __ No ___ Overactive ____ underactive Testicular pain/swelling: __ Yes __ No________________________________________________________ Hernias: __ Yes __ No ___________________________________________________________________ Autoimmune Disease: __ Yes __ No _________________________________________________________ Any Cancer History: __ Yes __ No

__________________________________________________________ Other Chronic illness: __ Yes __ No _________________________________________________________ Any previous radiation: __ Yes __ No If yes, When and where were you treated? _______________________ _______________________ MEN ONLY: Do you have regular PSA Tests? __ Yes __ No Date of last exam:

_______________________ WOMEN ONLY: Obstetrics/Gynecology history: Are you pregnant? __ Yes __ No Is there a chance you could be pregnant? __ Yes __ No Age of 1st menstrual period: __________ Date of last menstrual period: ______________ Age of Menopause ( if applicable): _____ Hysterectomy: __ Yes __No Ovaries removed? __ Yes __ No Type of birth control currently used: __________________ Do/did you use oral contraceptives: __ Yes __ No Do/did you use hormone replacement: __ Yes __ No If yes, For how long? ___________________________ Number of pregnancies: _____ Number of live births: _____ Age at first full term pregnancy: _____________ Date of last mammogram: ____________ Date of last PAP/pelvic exam:

______________________ Social History: Are you Married: __ Yes __ No What is your occupation: ________________________________________ Do you live: ___ Alone __ with spouse/significant other __ with family __ other ______________________ Any children: __ Yes __ No If so, How many? ___________

Do you have a religious and or cultural belief we should be aware of during treatment? __ Yes __ No

If yes, Please describe:___________________________________________________________________________ Health Maintenance: Do you have any dental problems? __ Yes __ No Dentures: __ Yes __ No Have you had a colonoscopy/sigmoidoscopy? __ Yes __ No If yes, date of last one:___________________ Have you has a flu vaccination? __ Yes __ No If yes, date of last vaccine: ___________________________ Have you had a pneumonia vaccination? __ Yes __ No If yes, date of last vaccine: ____________________ Consent to give immunization history to public health? __ Yes __ No Please indicate if you use any of the following regularly: __ crutches __ wheelchair __ walker __ cane __other Family History: Father: ___ Alive ___ Deceased ___ age Cause of death: _________________________________________ Mother: ___ Alive ___ Deceased ___ age Cause of death: _________________________________________ SIblings: Number of Sisters ____ Brothers ____ Number of deceased sisters ____ brothers _____________ Do/did any of your family member suffer from any form of cancer or blood disease?

Family member Type of cancer/blood disease Age at time of diagnosis

Alive/ Deceased

If deceased, cause of death

Substance History: Do you opr have you ever smoked? __ Yes __ No (If yes, please answer the following questions) Do you smoke cigarettes: __ Yes __ No Do you use chewing tobacco? __ Yes __ No Packs per Day: ________ How many years: ________ If you no longer smoke, date you quit:___________ Do you use recreational drugs? __ Yes __ No If yes, which drugs? ________________________________ Do you or have you ever consumed alcohol? __ Yes __ No If yes, How many drinks per week? ___________ If you no longer consume alcohol, when did you stop? ____________________________________________

Review of systems: ( please check all that applies) _ Recent weight change _ Chest Pain _ Rectal Bleeding _ headaches _ Loss of appetite _ Heart palpitations _ Bowel incontinence _ seizures _ fever _ Lightheadedness _ Burning on urinations _ Dizziness _ shaking/chills _ Swelling in legs _ pain with urination _ Loss of balance _ Night Sweats _ Passing out _ Blood in urine _ Weakness in limbs _ Fatigue _ Cough _ Frequent urination _ Loss of sensation _ Blurred vision _ Sputum production _ Urinary incontinence _ Numbness _ Double Vision _ Blood in sputum _ Muscle pain _ Tingling sensation _ Hearing loss _ Shortness of Breath _ Stiffness _ Memory Loss _ Ringing in ears _ Nausea _ Joint Pain/ Arthritis _ Difficulty thinking _ Sinus Trouble _ Heartburn _ Back Pain _ Lumps in armpits _ Trouble swallowing _ Vomiting _ Skin Rash _ Lumps in neck _ Sore Throat _ Constipation _ Skin Problems _ Breast Lumps _ Nose bleeds _ Diarrhea _ Nervousness _ Depression _ Hoarseness _ Abdominal Pain Patient Signature: ____________________________________ Date: ________________________ Reviewed By: _______________________________________ Date: ________________________

ACKNOWLEDGEMENT OF RECEIPT OF NOTIFICATION OF PRIVACY PRACTICES

Phoenix Cancer Institute is committed to protecting your privacy and ensuring that your health informations is disclosed appropriately. This Notice of Privacy practices identifies all potential uses and disclosures of your health information by our practice and outlines your right with regard to your health information. Please sign the form below to acknowledge that you have received out Notice of Privacy practices. I acknowledge I have received a copay of the Notice if Privacy Practices of Phoenix Cancer Institute. Patient or personal Representative ( please print): _________________________________________________+ Patient or personal Representative (Signature): ___________________________________________________ Date: _________________________________ ***************************************************************************************************************************** For Office Use Only” Reason acknowledgement was not obtained: _____________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Employee Initials: __________________ Doctor: _______________________ MRN #: ___________________

Authorization of release of information

Patient Name: _______________________________ Date of birth: _______________________

I Authorize Phoenix Cancer Institute to obtain information from my medical records from: I Authorize Phoenix Cancer Institute to release information from my medical records to:

Facility: Name:_____________________________________ Phone Number: (_____) ____- __________ Address: ______________________ City: _______________ State/Zip code: _______________ Family Member/friends: Name: ________________________________ Relationship to patient: ____________________ Name: ________________________________ Relationship to patient: ____________________ Name: ________________________________ Relationship to patient: ____________________ Name: ________________________________ Relationship to patient: ____________________ Please provide the following information from my medical records:

duplicate copy of ALL medical records I hereby consent to the release of all medical records pertaining to treatment/diagnosis except as follows: _______________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ The purpose of this request is for:

Further medical care Insurance Radiology ( all films are the property of the clinic & must be returned within 30 days) Other

I understand that this authorization shall expire, without my express revocation, 1 year from the date written below. I understand that a photocopy of this authorization is considered acceptable in lieu of the original. Patient signature: _____________________________________ Date: ____________________ Or Patient representative signature: ___________________________________________ Date: ____________________ Witness/office Employee signature: ___________________________________ Date: ____________________

 

Medication History Retrieval 

 

This form will be used to retrieve medication list and information from your pharmacy. However, in order to obtain this information we need your approval. Please check yes that you would like us to obtain medication information. ____ Yes please obtain my medication history. ____ No you may not obtain my medication history. ___________________________________ ____________________ Patient Signature Date ___________________________________ Print Patient Name In addition, we can send your prescription needs to your pharmacy electronically. However, to be able to do this we require the name and location of your pharmacy. ___________________________________________________________ Pharmacy Name ____________________________________________________________________________ ____________________________________________________________________________ Address, City, State and Zip code _____________________________________________________________ Pharmacy Telephone number

phoenixcancer.com

Patient Management Expectations

Sincerely, Your Care Team at PCI Signature:__________________________________ Date: ________________

Hello and welcome to Phoenix Cancer Institute! We are so happy to have you as our patient. Below are a few points of clarification so you know what to expect when it comes to communication and making sure you get the care your need.

_______Phone calls: If we are unable to answer your call and you leave a message on voicemail, we will return the call as soon as possible, but please allow up to 2 business days to return your call due to high patient call volume. If you are calling about an emergency, call 911. Multiple phone calls about the same issue are not required.

_______Clinician cell phone number: In some cases our clinicians have given out their cell phone numbers in order to follow up on specific issues. Following that specific situation, and outside of urgent issues, it is expected that the patients direct all other general calls to the clinic phone number.

_______Care team: At PCI we manage our patients as a team. This means that follow-up appointments may be with the primary oncologist or may be with other physicians or advanced practice practitioners on the care team.

_______Medication refills: Please allow 3-4 business days for all medication refills. To avoid delays, please notify us at least 5-7 business days in advance of the date that refills will be due.

_______Controlled substance management: For patients with cancer-related pain or anxiety, we may prescribe controlled substances to help with these symptoms during cancer treatment. The goal is to taper off these medications after the cancer is treated. Some patients will require a taper plan agreement at the clinician’s discretion. For patients unable to taper off the controlled substances following successful cancer treatment, they will be referred back to their PCP or pain doctor for ongoing management.

_______Paperwork: The majority of paperwork will require an appointment so it can be completed accurately based on each patient’s specific needs. Please allow 5-10 business days for completion of the paperwork from the date of the appointment, although most paperwork will be completed on the day of the appointment.

_______Respectful behavior towards staff: We strive to foster a supportive and positive environment. All employees are working very diligently on each patient’s behalf, often-times behind the scenes. Disrespectful behavior by the patient or family members (or their friends) will not be tolerated under any circumstance, including but not limited to yelling, cursing, physical aggression, verbal abuse over the telephone, etc. This kind of behavior may result in dismissal from the clinic.

_______We strive to keep your bills as low as possible, which is why we have made the PCI promise of seeking grant support for all patients, providing the lowest cost treatment regimens as long as efficacy is equivalent, and working to stay in network with insurance companies. We do not make treatment decisions based on what is most profitable for our clinic. Therefore, we expect that patients keep up to date with their bills and notify our clinic if additional assistance is needed or if insurance changes occur.

_______Missed appointments: our clinic runs best for patients and staff when patients are on time and do not miss scheduled appointments. Please call at least 24 hours in advance if you need to reschedule your appointment in order to avoid a $25 late fee. We understand emergencies come up, so please call our office to keep the lines of communication open.

_______Please notify us immediately if a pharmacy is charging you an unreasonable amount of money – we work to limit out of pocket expenses, but we need to be aware of them when they come up!

_______At this time, visitors are not able to stay in the treatment room while patients are getting chemotherapy for patient safety, privacy and comfort of other patients, and limited space. Thank you for your understanding.