EMERGENCY CONTACT

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.

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

I, (Patient's Name), 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 and Innovation.

The 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

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

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 posted in the clinic for review, available via The Oncology Institute of Hope and Innovation's("TOI") website, and personal copies are available for me upon request. Patient Signature:Date:

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 and Innovation("TOI") will not be liable for any consequence of that decision.

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 responsible 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 and Innovation("TOI") 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. Patient Signature:

Approval for assistance programs is not guaranteed and subject to approval under the program guidelines. Programs reserve the right to change or terminate the program without prior notice. Program assistance is subject to availability of funds at the time of request and is not a guarantee of payment. If a drug or date of service is not covered by the program assistance, the patient will be fully responsible for the cost. Program enrollment does require proof of income upon request. 

The Oncology Institute of Hope and Innovation("TOI") utilizes automated systems to send communications via text message and automated phone calls. In furtherance of TOI's obligations to safeguard patient privacy, TOI hereby seeks your express consent to communicate with you via text communications and automated phone calls. Frequency of communications will depend on treatment planning. Messaging will be from the clinical facility where you are receiving treatment. Message and data rates may apply.

Possible communication types include the following:

- Appointment Reminders Authorization Information and Updates

- Referral Information and Updates - Physician order information and updates regarding labs, imaging, and procedures

- Patient account balance, billing matters, and payment related items

- Registration documents By signing below, you hereby acknowledge, represent, and agree as follows:

CONSENT TO CONTACT: I hereby authorize TOI to contact me, by means of text message ("SMS") and telephone calls at any telephone number provided to TOI for the purposes of communicating information relating to patient account information, appointment reminders, authorization information and updates, referral information and updates, physician orders, practice notifications, patient account balance, billing matter, and any payment related items.

PROTECTED HEALTH INFORMATION: I understand that text messages may contain Personal Health Information (PHI) Reasonable efforts will be made to secure messages, but SMS is not a secure method of communication.

REVOKATION OF CONSENT: I understand that may revoke this authorization at any time. Revocation may be effected by providing written notice to TOI or by replying "STOP" to any SMS communication transmitted to me by TOI. I understand that such revocation will not affect any communications made prior to TOI's receipt and processing of my revocation. PRIVACY AND USE OF INFORMATION: I understand and acknowledge that TOI will not disclose my telephone number to any third party except as permitted or required by applicable law. I further understand that TOI shall use my telephone number solely for the purposes described herein.

 

The Oncology Institute of Hope and Innovation("TOl")is partnered with Ontada Health to provide a patient portal. Patient portal access allows secure, online access for patients to their health records, treatment history, including diagnosis information, medications, lab results, and more. Please indicate below if you would like to receive an invite to set up portal access:

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

The Oncology Institute of Hope and Innovation have collaborative services that may be available to patients through the Collaborative Care Model program (the "CoCM Program" Participation in the CoCM Program is voluntary. By signing below, I acknowledge and agree that:

1. I understand the services provided under the CoCM Program, including the roles of the behavioral health care manager and psychiatric consultant.

2. My provider may consult with relevant specialists for CoCM services, which includes talking with a psychiatric consultant. I have given my provider permission to consult with such relevant specialists.

3. I will be responsible for potential cost-sharing expenses for both in-person and non-face-to-face CoCM services even if supplemental insurance plans cover cost sharing. Any questions that I have regarding billing for CoCM Program services have been answered.

4. This consent will be included within my medical records and will be accessible to all members of my care team.

5. CoCM services will be delivered through telemedicine and will be administered remotely through a secure, electronic platform, using secure phone and/or video telecommunication. I understand that I will need to have access to a PC computer, laptop, or mobile device, and I will need adequate internet connection and/or telephone connection to receive CoCM services.

6. Telemedicine and the electronic nature of the CoCM services provided carry a greater risk to the privacy of my electronic health information relative to receiving in-person care. I understand that there are potential risks, including service interruptions, interception, breach, and technical difficulties.

7. To the extent I receive CoCM services that must be provided by a licensed individual, state licensure laws require that such services are provided by an individual who is licensed to practice in the state where I am located at the time I receive such services. I agree to accurately report my anticipated location when scheduling CoCM appointments, to update my care team if my location plans change prior to an appointment and reschedule if necessary, and to accurately provide my location at the beginning of each appointment.

8. I understand that by checking" DO" below, I am consenting to receive automated text messages from my provider, which may include, among other things, appointment reminders, communications about my health care, prescription refill reminders (if applicable), or other information related to the CoCM services.I acknowledge that message and data rates may apply. I understand that this consent is not a condition of my receipt of CoCM services and that I may reply "STOP" to opt-out of receiving automated text messages from my provider. 

 

9. I understand that unless I indicate otherwise below, any audio or video session that I have with a member of my care team may be recorded for quality assurance and improvement purposes. I understand that there are potential risks, including unauthorized access to such recordings. I understand that any video and audio recordings of my sessions will be the sole property of my care team, and that the recordings will be securely stored, using technical and administrative safeguards to reduce the risk of unauthorized access and/or breach.