In case of an emergency, the following individual you would like notified on your behalf.

This information is typically found on the back of your insurance card:

This information is typically found on the back of your insurance card:

It is important to provide you with continuity of care; we need the name and phone number of other physicians providing you care.

To Whom It May Concern:

I hereby authorize the release of all of my medical records including but not limited to office notes, test results, outside physician reports, and chemotherapy regimens to The Oncology Institute of Hope & Innovation.

This authorization is in effect until six months from the date of the signature below, at which time it expires. I understand that by signing this authorization:

• I authorize the use or disclosure of my individually identifiable health information as described above for the purposes listed. I understand that this authorization is voluntary.
• I understand the Notice of Privacy Practices provides instructions should I choose to revoke my authorization. 
• I understand if the organization I have authorized to receive the information is not a health plan or healthcare provider, the released information may no longer be protected by federal privacy regulations.
• I understand I have the right to receive a copy of this authorization.
• I understand that I am signing this authorization voluntarily and that treatment, payment, or eligibility for my benefits will not be affected if I do not sign this authorization.
• I declare under penalty of perjury that the information on this form is true and correct.

FINANCIAL RESPONSIBILITY

By signing below, I am acknowledging that I have indicated my insurance coverage and assign all medical benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsibile for all charges resulting from services rendered by the practice, whether they are paid by the insurance. I hereby authorize The Oncology Institute of Hope & Innovation to release all information necessary to secure the payment of benefits and further authorize the use of the signature on all insurance benefits.

It is our policy to collect co-pays and coinsurance payments upfront. We will verify with your insurance policy in advance of any co-pays and coinsurance not listed on your card, and we will collect at the time of service. You may also be responsible for other charges that may incur at the time of service after your co-pay or coinsurance has been collected. Any coinsurance not listed on your insurance card will be collected as an approximate based on Medicare fee schedules; anything above our calculations that your insurance company has processed as allowable will still be due. You will receive a monthly statement regarding any open balances. If you have any questions or concerns regarding your co-pays or coverage, please call your insurance company member services.

ACKNOWLEDGEMENT OF RECEIPT

By signing below, I acknowledge that a copy of the Notice of Privacy Practices, HIPAA Privacy Policies, Medicare Prescription Drug Coverage and Your Rights, and Patient Rights and Responsibilities are available in the clinic for review and also personal copies are available for me upon request.

CONSENT TO TREAT

I consent to the administration and performance of all medical and radiation oncology related procedures which, in the judgment of the physician / healthcare practitioner may be considered necessary and advisable. I also agree that should I elect to suspend or discontinue treatment against the consent of my physician, then The Oncology Institute of Hope & Innovation will not be liable for any consequence of that decision.

CONSENT TO DISCLOSE HEALTH INFORMATION

I understand that The Oncology Institute of Hope & Innovation is a healthcare provider and that they may share my health information for treatment, billing, and healthcare operations with one or all the designated parties listed below once identity is verified.

I further understand that The Oncology Institute of Hope & Innovation may share deidentified health information with other entities for medical research purposes. This information, once de-identified, is no longer considered personal health information.