Tampa Bay Radiation Oncology - Patient Information Sheet · 2016. 1. 7. · WEST TAMPA 5931 WEBB ROAD TAMPA, FL 33615 813-886-9277 FAX. 813-886-9377 TAMPA (BBD) 12206 BRUCE B. DOWNS

John R. “Jack” Steel, M.D. FACRO

Board Certified in

Radiation Oncology

Randy Kahn, M.D., FACRO

Board Certified in Radiation Oncology

& Internal Medicine

Harvey Greenberg, M.D., MBA

Board Certified in Radiation Oncology

Medical Oncology & Internal Medicine

John M. Koval, M.D.

Board Certified in

Radiation Oncology

Patient Information Sheet

Tampa Bay Radiation Oncology Brandon Sun City Center Tampa West Tampa

Patient Name: ___________________________________________________________________________ Date: _________________________

Last First Middle Initial

Home phone: ______________________ Cell Phone: ___________________ Email:______________________________ Facebook __Y __N

Address: ______________________________________________________________________________________________________________

Secondary Address: _____________________________________________________________________________________________________

Patient’s D.O.B. ________/_________/_________ Age: ____________ Patient Social Security #: __________ -__________-___________

Spouse Name: ______________________________________________ Phone: ________________________ Cell Phone:____________________

Spouse D.O.B. ________/_________/__________ Age: ____________ Spouse Social Security #: __________ -__________-___________

Please Check One: Married Divorced Widowed

Emergency Contact (other than spouse):________________________________________________ Relationship:___________________________

Address: _______________________________________________________________________ Phone: ________________________________

Referring Physician:___________________________________________ Primary Physician: __________________________________________

Medical Oncologist:___________________________________________ Surgeon: __________________________________________________

Other than your Referring Physician, how did you first hear about us? (Please check all that apply)

Website Radio TV Ad Magazine Ad Newspaper Ad Yellow Pages Friend Presentation

Employer: __________________________________________ Occupation: ____________________________ Retired or Active?_____________

Address: _______________________________________________________________________________ Phone: _________________________

PRIMARY INSURANCE:____________________________________________________________ Phone: ____________________________

Insured’s Name: ___________________________________________________________ Relationship: __________________________________

Policy #: __________________________________________________________________ Group #:____________________________________

Benefit Coverage/ Copy: _________________________________________________________________________________________________

SECONDARY INSURANCE:__________________________________________________________ Phone: ___________________________

Insured’s Name: ____________________________________________________________ Relationship: _________________________________

Policy #: __________________________________________________________________ Group #:____________________________________

Benefit Coverage/ Copy: _________________________________________________________________________________________________

ADDRESS FOR CLAIMS: _______________________________________________________________________________________________

AUTHORIZATION FOR RELEASE OF INFORMATION AND ASSIGNMENT OF BENEFITS: I authorize the release of any medical or other

information necessary to process insurance claims on my behalf. I also request payment of government benefits either to myself or to Tampa Bay

Radiation Oncology, who accepts assignment. I further authorize payment of medical benefits to Tampa Bay Radiation Oncology for services

rendered.

Patient or authorized signature: ____________________________________________________________ Date: _______________________

Witness: ____________________________________________________________________ (New patient packets/patient information sheet 3-4-15)

Tampa Bay Radiation Oncology

John R. “Jack” Steel, M.D.

FACRO

Board Certified in

Radiation Oncology


Board Certified in

Radiation Oncology

& Internal Medicine

Harvey M. Greenberg, M.D., MBA

Board Certified in

Radiation Oncology, Medical

Oncology & Internal Medicine

John M. Koval, M.D.

Board Certified in

Radiation Oncology

SUN CITY

4031 UPPER CREEK DR.

SUNCITY CENTER, FL 33573

P813-633-2733

FAX. 813-634-8601

BRANDON

823 S. PARSONS AVE

BRANDON, FL 33511

813-685-2440

FAX. 813-685-3019

WEST TAMPA

5931 WEBB ROAD

TAMPA, FL 33615

813-886-9277

FAX. 813-886-9377

TAMPA (BBD)

12206 BRUCE B. DOWNS BLVD SUITE 101

TAMPA, FL

813-971-8276

FAX. 813-971-8277

G:/Forms/New patient packets/Disclosure of Health Information Authorization 05-31-2011

Authorization for Disclosure of Health Information

Patient: ______________________________________________________ Date: _____________

Date of Birth: SSN:

1. I hereby authorize to disclose to

Tampa Bay Radiation Oncology, Dr Steel, Dr Kahn, Dr Greenberg and Dr. Koval my medical

information.

2. I hereby authorize Dr. Steel, Dr Kahn, Dr Greenberg, Dr. Koval and/or their staff to discuss my medical

condition and treatment plan with:

3. Information to be disclosed:

[ ] Complete copy of Medical Records [ ] History and Physical [ ] Physician Progress Notes

[ ] Lab Reports [ ] Consultation Reports [ ] Nurses Notes

[ ] X-Ray Reports [ ] X-Ray Films

[ ] Other (Please Specify)

[ ] Re-disclosure of death records from the facility of:

4. I understand that this will include information of super confidential nature relating to: (Check if applicable the appropriate block along with initials by the patient)

[ ] Acquired Immunodeficiency Syndrome (AIDS) or infection with HIV (Human Immunodeficiency Virus)

documentation and/or testing results.

[ ] Psychiatric care documentation.

[ ] Alcohol and/or drug abuse documentation.

5. I understand this authorization may be revoked in writing at any time, except to the extent that action has

been taken in reliance on this authorization.

6. The facility, its employees, officers and physicians are hereby released from any legal responsibility or

liability for disclosure of the above information to the extent indicated and authorized herein.

SIGNED:

Patient Signature Date

Legal representative & relationship to patient if patient unable to sign Date

WITNESS:

Date

TAMPA BAY RADIATION ONCOLOGY, P.A.

Patient Health History Form / Questionnaire

Date: _____/_____/_____

Name: _________________________________________ Date of Birth: _____/_____/_____ Age: _____ Last First Middle

Phone: _____________________ SSN: _______________________ Marital status: (circle) S M D W

Referring Physician: ___________________________ Family Physician: __________________________

What medical concern brings you to this office? ________________________________________________

Do you have a(n)… (circle all that apply) Living Will / Healthcare Surrogate / Advanced Directive

Please Note: This is a confidential record of your medical history and will be kept at this office.

Information listed here will not be released to any person except when you have authorized us to

do so. Please answer all questions. If you are unable to answer any questions, please circle it and

call it to the attention of the doctor.

MEDICAL HISTORY: (Please check all that apply and include dates)

Questions Yes No When

Do you have a history of any prior radiation treatment?

Do you have a history of Cancer?

Could you be pregnant?

Do you have a pacemaker or defibrillator?

Do you have a history of blood disease?

Other: _____________________________________________________

If yes, explain: _____________________________________________________________________________

Prior Treatment Yes No When Symptoms Yes No When

Chemotherapy/drug Weight loss (________) lbs

Radiation Weight gain (________) lbs

Surgery Chills/Fever

Other Fatigue

X-ray treatment of: Night Sweats

Skin Are you up most of the day

Thyroid In bed more than half the time

Tonsils Pain (if yes see below)

Additional symptoms: _______________________________________________________________________

Pain – Where / Intensity / Duration: ____________________________________________________________

_________________________________________________________________________________________

MEDICAL HISTORY (continued): (Please be as thorough as possible)

Other Medical Problems (Diabetes, Hypertension, Etc.)

Date Doctor Diagnosis Date Doctor Diagnosis

(Please list ALL medications – prescription and over the counter)

Allergies

Do you have any drug/other allergies? (Circle) Yes / No - If yes, please list below:

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

What is an allergic reaction like for you? ________________________________________________________

Medications (prescription and over the counter)

Medication Dosage Times per day How long? Reason for medication/RX?

HOSPITALIZATIONS / SURGERIES: (List all hospitalizations and surgeries. If none, write none.)

Year

Duration

Reason / Result

Hospital / Physician

Any recommended surgical operations which you have not undergone? (circle) Yes / No

If yes, describe: ___________________________________________________________________________

_________________________________________________________________________________________

FAMILY HISTORY: (Please check all that apply)

Condition/Ailment Yes No Condition/Ailment Yes No Condition/Ailment Yes No

Diabetes Anemia Cancer

Heart Disease Kidney Disease Melanoma

Strokes Tuberculosis Bleeding Tendency

Additional Information: ______________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Family Medical Status

Father Mother Brother(s) Sister(s)

Age

Alive / Expired

Cause of Death

Medical Problems

Significant illness in children _________________________________________________________________

_________________________________________________________________________________________

Are there any diseases or problems you would like to discuss that are not written on this questionnaire?

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

FEMALE HISTORY ONLY: (Please check all that apply & include dates & locations when applicable)

Have you had… Yes No When / Where

History of Menstrual Irregularity

Vaginal Bleeding (Currently)

Use of Hormones During Menopause

Breast Fed Infant

Breast Discharge

Breast Swelling

Breast Pain

Breast Mass

Breast Biopsy

Abnormal Mammogram

Mastectomy

Vaginal Discharge

Pelvic Pain

D & C

Hysterectomy

Removal of Ovaries

Questions Response / Date

What was your age when you began menopause?

Did your menopause begin naturally or surgically?

What was your age at the time of your first menses (period)?

How many times have you been pregnant?

How many live births have you had?

What was your age at the time of your first delivery?

What means of birth control have you used?

When was your last menstrual period?

When was your last mammogram?

When was your last pap smear?

Additional Symptoms: _______________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

SOCIAL / MISC HISTORY: (Please respond and circle when applicable)

Questions Response

What is your highest level of education completed? (Circle) G: 7 8 9 10 11 12 College: 1 2 3 4 P.G.

Who do you live with?

Do you drive? If no, how do you get around?

Have you ever smoked?

Do you smoke? (Cigarettes, Cigars, Hookah, or E-Cigarettes)

If you smoke(d), how many per day & for how many years? ________________ per day for _______ years.

Did you quit? (Circle) If yes, when? Yes / No - When (if applicable): ____________

Do you want to quit smoking? (Circle) Yes / No

Are you ever exposed to second hand smoke? (Circle) Yes / No

Do you use chewing tobacco? (Circle) Yes / No

Do you drink alcoholic beverages? (Circle) How Many? Yes / No - ___________ per day / month / yr.

Have you ever felt the need to cut down on your drinking? Yes / No

Have people annoyed you by criticizing your drinking? Yes / No

Have you ever felt guilt about drinking? (Circle) Yes / No

Have you ever felt the need to drink first thing in the

morning (Eye Opener) in order to steady yourself? (Circle) Yes / No

Do you have a History of Hepatitis B? (Circle) Yes / No - if yes, Acute / Chronic (Circle)

Do you have a History of Hepatitis C? (Circle) Yes / No - if yes, Acute / Chronic (Circle)

Have you ever received treatment for Hepatitis C? (Circle) Yes / No

Do you have HIV? (Circle) Yes / No

Have you had an organ transplant? Yes / No - If yes, see below

If yes, do you take immunosuppressants (Cyclosporine, etc.) Yes / No

Have you ever been told to take antibiotics after a dental

procedure? (Circle) Yes / No

Have you had any prior blood transfusions? (Circle) Yes / No - If yes, When? _________________

Have you received vaccinations for the Flu? (Circle) Yes / No - If yes, When? _________________

Have you received vaccinations for Pneumovax? (Circle) Yes / No - If yes, When? _________________

Have you received vaccinations for Hepatitis? (Circle) Yes / No - If yes, When? _________________

SOCIAL / MISC HISTORY (continued): (Please respond and circle when applicable)

Additional Information:

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Patient Signature: ____________________________________________________ Date: ________________

Would you like a copy of this questionnaire? (Circle) Yes / No

Occupational Exposure

Have you had exposure to: Yes No When Have you had exposure to: Yes No When

Asbestos Agent orange

Toxic metals/radioactive material Worked in a mine

Vinyl Chloride/toxic chemicals Lived on a farm

Current Occupation: ________________________________________________________________________

If Retired, last employment: __________________________________________________________________



FACRO

Board Certified in

Radiation Oncology


Board Certified in

Radiation Oncology

& Internal Medicine


Board Certified in



John M. Koval, M.D.

Board Certified in

Radiation Oncology

New patient packets/TBRO Agreement Sheet 02/11/14

Agreement Form Date: ____________

I CONSENT TO TREATMENT: I consent to the examinations, treatments, and procedures that may be performed during my affiliation with Tampa Bay Radiation

Oncology, PA. If I am the representative/responsible party for another person or a minor, I also provide such authorization. This

will include radiological examinations, laboratory procedures, medical and non invasive treatments or procedures, or other medical

and medically related services rendered to the patient under the general and special instructions of the physician(s) or allied health

care providers of Tampa Bay Radiation Oncology, PA. Additional consent may be required for surgical or invasive procedures. I

have the right to revoke in writing, in the future, this authorization, however, Tampa Bay Radiation Oncology, PA reserves the

right to seek payment for services it provided under an earlier authorization and meet legal obligations related to those services.

Initials ________

II AUTHORIZATION FOR RELEASE OF INFORMATION: I understand and agree that, to the extent necessary to determine liability for payment and to obtain reimbursement, Tampa Bay

Radiation Oncology, PA may disclose information in a patient’s record to any person or entity that is or may be liable for all or

any portion of Tampa Bay Radiation Oncology, PA’s charges, including but not limited to, insurance companies, health care

service plans, or worker’s compensation carriers. The undersigned further consents to the release of information in a patient’s

record to there health care providers, referring physicians, and to outside medical facilities as is appropriate to expedite medical

care. Medical information may also be used to confidential quality care studies.

Initials ________

III LIFETIME AUTHORIZATION – MEDICARE CERTIFICATION OF PAYMENT: I certify that the information given by me in applying for payment under Titles XVII or XVIII of the Social Security Act (i.e.

Medicare) is accurate and correct. I authorize any holder of medical or other information about the patient or myself I represent, to

release to the Social Security Administration of its intermediaries or carriers any information of documentation needed for this or

related Medicare claim. I request that the payment of authorized benefits payable for physician services to the physician or

organization furnishing the services, and hereby authorize such physician or organization to submit a claim to Medicare for

payment.

Initials ________

IV ASSIGNMENT OF INSURANCE OR THIRD PARTY BENEFITS: I authorize direct payment to Tampa Bay Radiation Oncology, PA or any insurance, managed care, self-insured plan or other third

party benefits or state disability benefits otherwise payable to or on behalf of myself or the patient for services rendered, and

assigned Tampa Bay Radiation Oncology, PA, for the application to patient’s account all such benefits, payable at a rate not to

exceed Tampa Bay Radiation Oncology, PA’s regular charges, and rates. I understand that I, or the patient I represent, will remain

responsible for all charges or applicable co-payments not covered in whole ore in party by the payer, subject to applicable law.

Initials ________



FACRO

Board Certified in

Radiation Oncology


Board Certified in

Radiation Oncology

& Internal Medicine


Board Certified in



John M. Koval, M.D.

Board Certified in

Radiation Oncology

New patient packets/TBRO Agreement Sheet 02/11/14

V FINANCIAL RESPONSIBILITY AGREEMENT: By signing this agreement, whether signing as patient, representative or guarantor, I fully understand and hereby acknowledge and

agree that, if the services to be rendered are not covered by insurance, as an employee benefit program, Medicare, Medicaid, or a

health maintenance organization, then I am directly and completely responsible to Tampa Bay Radiation Oncology, PA for

payment of all charges. I also understand that I am responsible for all charges if I am covered by health insurance, or a health

maintenance organization with which Tampa Bay Radiation Oncology, PA does not hold a contract. Payment for any such

services shall become due and owing when the services are rendered, and I agree to be liable for the payment of the services,

provided that Tampa Bay Radiation Oncology, PA will attempt to obtain payment for any such services from the insurance or

employee benefit program and it affiliated physician(s) and allied health providers(s) in consideration for Tampa Bay Radiation

Oncology, PA’s administration of any insurance, claims. I further understand and agree that my obligation to pay is not contingent

on any settlement, judgment, or verdict that I may eventually recover from my third party, and that payment is due and must be

paid upon demand by Tampa Bay Radiation Oncology, PA. Should the account be referred to an attorney or collection agency for

collection, I shall pay actual attorney’s fees and collection expenses.

Patient Initials ________

Guarantor’s Initials ________

VI PHYSICIAN’S RIGHT TO DENY: I understand that should I request to see and copy my medical records, and I have refused to sign section II of this Agreement

Form, that the physician has the right to deny that request if a written reason for the denial is provided. Following a request denial,

I have the right to request review by an impartial reviewer. The contact person at Tampa Bay Radiation Oncology, PA is the

practice administrator.

Initials ________

VII CONSENT FOR PATIENT PHOTOGRAPHY: I understand and consent to photographs that may be recorded of my treatment site(s) for medical care documentation. Tampa Bay

Radiation Oncology, PA retains ownership rights to these images as a permanent part of my medial record and will be released

only upon written authorization.

Initials ________

I certify that I have read the foregoing and I am the patient, guarantor, or the patient’s representative

duly authorized to execute this agreement and accept its terms.

Patient or Patient Representative Signature Print Name

____________________________________________________________________________________ Guarantor Signature Print Name

Witness Signature Print Name

New patient packets/notice of privacy policies and practices 03/27/07


Notice of Privacy Policies and Practices At Tampa Bay Radiation Oncology, we are committed to handling protected health information about your care responsibly. This Notice describes the personal information we collect, and how and when we use or disclose that information. It also describes your rights as they relate to your protected health information. This Notice is effective April 14, 2003 and applies to all protected health information as defined by federal regulations.

UNDERSTANDING YOUR MEDICAL RECORD / HEALTH INFORMATION

Each time you visit Tampa Bay Radiation Oncology a record of your visit is made. Typically, this record contains information about your visit including your examination, diagnosis, test results, treatment as well as other pertinent healthcare data. This information often referred to as your health, or medical record, serves as a:

Basis for planning your care and treatment

Means of communication with other health professionals involved in your care

Legal document outlining and describing the care you received

A record that you, or another payer (your insurance company) will use to verify that services billed were actually provided.

An education tool for medical health providers

A source for medical research

Basis for public health officials who might use

A tool that we can reference to ensure the highest quality of care and patient satisfaction Understanding what is in your record and how your health information is used helps you to ensure it’s accuracy, determine what entities have access to your health information, and make an informed decision when authorizing the disclosure of this information to other individuals.

YOUR RIGHTS

You have certain rights under the federal privacy standards. These include:

The right to request restrictions 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 or submit corrections to your 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

OUR RESPONSIBILITIES

Tampa Bay Radiation Oncology is required to:

Maintain the privacy of your health information

Provide you with this Notice as to our legal duties and privacy practices with respect to information we collect and maintain about you

Abide by the terms of this notice

Notify you if we are unable to agree to requested restriction

Accommodate reasonable request you may have regarding communication of health information via alternative means and locations

As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state regulations. Whatever the reason for these revisions, we will provide you with a revised notice on your next office visit. The revised policies an practices will be applied to all protected health information that we maintain. We will not use or disclose your health information without your authorization, except as described in this notice. We will also discontinue to use or disclose your health information after we have received a written revocation of the authorization according procedures included in the authorization.

*Please see reverse*

New patient packets/notice of privacy policies and practices 03/27/07

HOW WE MAY USE AND / OR DISCLOSE YOUR HEALTH INFORMATION

We will use your information for treatment. Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example: results of laboratory tests and procedures will be available in your medical record to all health professionals who may provide treatment or who may be consulted by staff members. We will use your information for payment. Your health plan may request and receive information on dates of service, the services provided, and the medical condition being treated in order to pay for the service rendered to you. We will use your information for regular health operations. Your health information may be used as necessary to support the day to day activities and management of Tampa Bay Radiation Oncology. For example: information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality. Business Associates. In some instances, we have contracted separate entities to provide services for us. These “associates” require your health information in order to accomplish the tasks that we ask them to provide. Some examples of these “business associates” might be a billing service, collection agency, answering services and computer software / hardware provider. Communication with family. Due to the nature of our field, we will use our best judgment when disclosing health information to a family member, other relatives, or any other person that is involved in your care or that you have authorized to receive this information. Please inform the practice when you do not wish a family member or other individual to have authorization to receive your information. Research / Teaching / Training: We may use your information for the purpose of research, teaching, and training. Healthcare Oversight: Federal Law requires us to release your information to an appropriate health oversight agency, public health authority or attorney, or other federal / state appointee if there are circumstances that require us to do so. Public Health Reporting: Your health information may be disclosed to public health agencies as required by law. Law Enforcement: Your health information may be disclosed to law enforcement agencies, without your permission, to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government mandated reporting. Appointment Reminders: The practice may use your information to remind you about upcoming appointments. Typically, appointment reminders are sent by mail in a closed envelope, or a brief nonspecific message may be left on your answering machine. If you don’t approve of these methods, or, if you prefer alternative methods (i.e. email) please inform the practice. Other uses and disclosures: Disclosure of your health information on its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or 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 before you notified us of your decision.

FOR MORE INFORMATION OR TO REPORT A PROBLEM

If you have complaints, questions, or would like additional information regarding this notice or the privacy practices of Tampa Bay Radiation Oncology, please contact our Compliance Officer, Teresa Masse, at 813-633-2733. If you believe that your privacy rights have been violated, please contact the aforementioned practice Compliance Officer, or you may file a complaint with the Office of Civil Rights, U.S. Department of Health and Human Services. There will be no retaliation for filing a complaint with either the practice’s Compliance Officer or with the Office for Civil Rights. The address for the Office of Civil Rights is listed below:

Office of Civil Rights U.S. Department of Health and Human Services

200 Independence Avenue, S.W. Room 509F, HHH Building Washington, D.C. 20201



FACRO

Board Certified in

Radiation Oncology


Board Certified in

Radiation Oncology

& Internal Medicine


Board Certified in



John M. Koval, M.D.

Board Certified in

Radiation Oncology

New patient packets/notice of privacy practices 02/11/14

Acknowledgement of Receipt of Notice of Privacy Practices

Tampa Bay Radiation Oncology is committed to protecting your privacy and ensuring that you health information is used and disclosed appropriately. This Notice of Privacy Practices identifies all potential uses and disclosure of your health information by our practice and outlines your rights with regard to your health information. Please sign the form below to acknowledge that you have received our Notice of Privacy Practices. I acknowledge that I have received a copy of the Notice of Privacy Practices of Tampa Bay Radiation Oncology.

Name:

Signature:

Name of Personal Representative (If appropriate):

Signature of Personal Representative:

Date:

TAMPA BAY RADIATION ONCOLOGY USE ONLY

Date Acknowledgement received:

or

Reason acknowledgement was not obtained:



FACRO

Board Certified in

Radiation Oncology


Board Certified in

Radiation Oncology

& Internal Medicine


Board Certified in



John M. Koval, M.D.

Board Certified in

Radiation Oncology

New patient packets/radiation consent form 02/11/14

Courtesy Insurance Billing Service Authorization With this service, we are able to bill your insurance directly and save you the paperwork. We need

the following authorization from you in order for this to work correctly:

We will submit claims for services provided by TBRO to your insurance company.

PLEASE READ THE FOLLOWING IMPORTANT INFORMATION

1. We expect full payment from your insurance company within forty-five (45) days of date of service. If your insurance company has not paid by then, you will be sent a bill and need to make the payment within thirty (30) days. Your account balance remains your responsibility.

2. Under our Courtesy Billing Program, we have asked your insurance company to pay is directly, however, some insurance companies may pay the patient instead. If this occurs, you should sign the check over to TBRO, mail it with the insurance explanation of benefits and the stub from your monthly statement.

3. You must notify us IMMEDIATELY of any change in your insurance coverage or address/telephone number.

4. Account balances not paid after sixty (60) days may be subject to a 1.5% per month late payment charge. This charge will be billed to you not to your insurance company.

I have read the above Courtesy Insurance Billing Program, and understand all aspects of the program. I understand that I will be responsible for any amount not paid by my insurance within forty-five (45) days. _____________________________________________ _____________________________

Patient Signature Date _____________________________________________ _____________________________

Guarantor’s/Spouse’s Signature Date

ESTE FORMULARIO SE PUEDE OBTENER EN ESPANOL.

I UNDERSTAND THAT I AM RESPONSIBLE FOR ANY AMOUNT NOT COVERED BY

INSURANCE AND I HREBY AGREE TO PAY AS SPECIFIED BELOW.



FACRO

Board Certified in

Radiation Oncology


Board Certified in

Radiation Oncology

& Internal Medicine


Board Certified in



John M. Koval, M.D.

Board Certified in

Radiation Oncology

New patient packets/radiation consent form 02/11/14

PATIENT CONSENT FORM (Radiation Oncology)

Tx Site(s):

I hereby agree to give my consent for radiation therapy treatment. The treatment procedures and medically acceptable alternative procedures and treatments have been explained to me. Various risks, hazards, side-effects and complications from radiation therapy have also been explained to me. I understand that the explanation of the risks and consequences is not exhaustive and that other, more remote side-effects may arise. The side-effects may consist of redness, tanning, or occasional temporary blistering of the skin. Other side-effects occur from radiation therapy itself, as they can with any other major type of therapy, such as surgery or the administration of certain medications. I have been advised that other more remote risks and consequences will be explained to me upon request. I acknowledge that I have received no assurances of successful outcome concerning the radiation therapy to which I am consenting. I hereby agree not to hold the physician, or any assistant or associates, responsible or liable for any side-effects or complications which may rise now or later, including sterilization. I understand that if I have any symptoms that I think are due to these treatments, I will immediately call my radiation oncology physician, as well as my referring physician. NOTE: If you think you are pregnant or are trying to become pregnant, please let us

know prior to your first treatment. If you become pregnant during treatment, please let us know immediately.

I have read the above. I acknowledge that I have a general understanding of my treatment procedure, the medically acceptable alternative procedures or treatments, and the substantial risks and hazards inherent in the proposed treatment or procedures. I understand that I have the right to ask any questions at any time regarding the treatment and any possible risks, hazards, side-effects or complications that may arise from radiation therapy. Witness Patient Signature Date Date

ESTE FORMULARIO SE PUEDE OBTENER EN ESPANOL.

Documents

Tampa Bay Radiation Oncology - Patient Information Sheet · 2016. 1. 7. · WEST TAMPA 5931 WEBB ROAD TAMPA, FL 33615 813-886-9277 FAX. 813-886-9377 TAMPA (BBD) 12206 BRUCE B. DOWNS