Healthcare Cancer Application Form

Healthcare Cancer Application Form

Program Application and Certification

I apply for enrollment in the oncology support and treatment coordination program. I authorize the program to review clinical and insurance information to determine eligibility and to coordinate care. I certify that the information supplied on this application is complete and accurate to the best of my knowledge. I understand that falsification may result in denial or termination of services.

Patient Information

Date of Birth:    Gender:

Emergency Contact

Insurance Information

Policy Number:    Group Number:

Subscriber Date of Birth:    Relationship to Patient:

Cancer Diagnosis and Clinical History

Date of Diagnosis:    Stage at Diagnosis:

Metastatic Disease Present: Yes No

Current Treatment and Medications

Current Treatment Plan (check all that apply):
Chemotherapy    Radiation Therapy    Surgery    Immunotherapy    Targeted Therapy    Palliative Care    Clinical Trial

Treatment Start Date:    Last Treatment Date:

Medical Conditions and Functional Status

Chronic Conditions (check all that apply):
Diabetes    Hypertension    Heart Disease    Renal Disease    Liver Disease    Other

Treating Physician / Facility

Authorization to Release and Exchange Medical Information

I authorize my treating providers, hospitals, laboratories, and insurers to disclose medical records, treatment summaries, and billing information related to my cancer diagnosis and treatment to the oncology program named above for purposes of eligibility determination, care coordination, payment assistance, and clinical coordination. This authorization includes release of pathology reports, imaging reports, operative reports, chemotherapy records, and relevant laboratory data.

I understand that information disclosed under this authorization may include records relating to infectious disease, mental health, drug or alcohol treatment only if such information is necessary for treatment coordination. I understand that I may revoke this authorization at any time by providing written notice, except to the extent actions have already been taken in reliance on this authorization.

By checking the box below I acknowledge that I have read and consent to the release and exchange described above.

I acknowledge and authorize release and exchange of medical records as set forth above.

HIPAA Authorization and Privacy Acknowledgment

I acknowledge receipt of the program's privacy practices and understand how my protected health information will be used and disclosed for treatment, payment, and healthcare operations. I authorize use and disclosure of my protected health information consistent with the program's privacy practices for the purposes articulated in this application.

I acknowledge receipt of the privacy notice and authorize use/disclosure as described.

Financial Responsibility and Program Conditions

I understand that acceptance into the program may be contingent upon verification of diagnosis, insurance eligibility, and available program resources. I accept responsibility for any charges not covered by insurance and agree to cooperate with program staff in obtaining prior authorizations and benefits. Enrollment does not guarantee coverage of specific treatments or medications.

I understand that I may withdraw this application or authorization at any time in writing, and that withdrawal will not affect any actions taken in reliance on this application prior to receipt of written withdrawal.

Attestation

I certify under penalty of perjury that the information provided in this application is true, accurate, and complete. I understand that any material misrepresentation may lead to denial or termination of program services and may be subject to applicable civil or criminal penalties.

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