Radiation New Patient Packet - Arizona Oncology

Please fill out the following questionnaire to the best of your ability. This

information is necessary in case your provider requests additional testing.

Completing this form will enable our office to schedule you appropriately and

timely. Please note: We will ask you to update this questionnaire periodically. Thank

you.

Name: ________________________________ DOB: ____________________________

Daytime Phone #: _______________________ Other #: __________________________

Primary Insurance: ______________________ Circle: PPO HMO SENIOR OTHER

Secondary Insurance: ____________________ Circle: PPO HMO SENIOR OTHER

Where would you like exams (e.g. Cat Scan) to be scheduled?

________________________________________________________________________

Please Circle All Applicable

Available Days: Mon Tues Wed Thurs Fri Sat All

Available Times: Morning Afternoon Early Evening Any

Allergic to: Iodine Shrimp Lobster Shellfish None

Are you Diabetic? Yes No

If so, what medication(s)? ____________________________________________

Do you have hypertension? Yes No

Are you taking blood thinners? Yes No

If so, what medication(s)? ____________________________________________

List any implants: __________________________ Date placed: ___________________

List any metal in body: ______________________ Date placed: ___________________

Do you have a pacemaker? Yes No

Do you have both kidneys? Yes No

Any history of Renal Failure? Yes No

List any breast problems: ___________________________________________________

Do you have asthma? Yes No

Are you Claustrophobic? Yes No

Are you or could you be pregnant? Yes No

Do you have any tattoos? Yes No Date Received__________

Location of tattoo on body___________

List any other operations: __________________________________________________

Patient Signature _________________________________ Date: __________________

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Original - Medical Record Copy - Patient or Personal Representative

ARIZONA ONCOLOGY

CONTACT LIST

The purpose of this form is to provide Arizona Oncology with the names of people to be contacted on your behalf.

Emergency: Indicate any person who should be notified in case you experience a medical emergency while at our office.

Other contacts: Indicate persons who we may contact if we are having difficulty reaching you

Emergency Contact Name:

Relationship:

Primary Phone Number: Alternate Phone Number:

Other Contact Name:

Relationship:


Contact Name:

Relationship:


Contact Name:

Relationship:


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Patient Signature Date/Time AM or PM (circle one)

x

Print Name

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Personal Representative Signature Relationship Date/Time AM or PM (circle one)

PHYSICIAN: EMPLOYEE INITIALS

MRN: LOC:

FOR OFFICE USE ONLY

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Rev. July 2014

PHYSICIAN REFERRAL FOR IMAGING (PET OR CT)

Your physician has ordered an imaging study (either Pet or CT) as part of the medical management of your care. Our practice has the

ability to perform the scan and has been accredited by the American College of Radiology (ACR) as a provider of the service based on

its ability to satisfy ACR’s rigorous, objective criteria for image quality, personal qualifications and continuing education. Additionally,

the long-term and comprehensive management of your oncology care (treatment, imaging, follow up) is centralized at our practice,

making it both convenient and advantageous for you to receive the service from this practice.

It is important for you to know that the imaging study your physician has ordered can also be obtained from other imaging service

providers in the area. In evaluating the decision to choose another imaging provider, please take into consideration that not all

imaging providers specialized in cancer care or cancer-related imaging nor are all the providers accredited by the American College

of Radiology. Should you choose to evaluate another provider to perform the scan, we strongly urge you to explore these points

The list below is designed purely as a resource to patients and does not necessarily include the names of all providers of imaging

service in our community. Please keep in mind that your physician has made the medical decision to order this study and considers it

medically necessary regardless of where you choose to have it performed. Should you decide to have the imaging study performed

elsewhere, it will not affect your continuing treatment with your physician

Other CT Providers:

Provider Address Phone

Scottsdale Medical Imaging. Ltd. Multiple Location throughout Valley (480)425-5030

http://www.esmil.com/

Arizona Radiology-SMIL 2222 E. Highland Ave Suite #120 (602)977-1177

Phoenix, AZ 85015

Desert Valley Radiology Multiple Locations throughout Valley (602)954-0954

http://dvrphx.com/

Insight Imaging 2141 E. Camelback Road, Ste.110

Phoenix, AZ 85016

Other PET Providers

Provider Address Phone

Scottsdale Medical Imaging Ltd 9003 E. Shea Blvd (480)425-5030

Scottsdale, AZ 85260

SimonMed Imaging Inc. 20830 N Tatum Blvd (480)306-7900

Phoenix, AZ 85050

I would prefer to obtain my imaging study from:

__ My treating physician office. –or- __ Another Provider of my selection

If additional scans are needed later in your treatment, having those scans performed on the same machine helps maintain

consistency and comparability throughout all scans. Therefore, your above preference will also determine where any later scans will

be performed.

______________________________________ ____________________________

Patient Signature Date

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Other Uses and Disclosures of Your Health Information:Other uses and disclosures of your health information notcovered by this Notice or the laws that apply to us will bemade only with your authorization. If you authorize us touse or disclose your health information, you may revokethat authorization, in writing, at any time. If you revokeyour authorization, we will no longer use or disclose yourhealth information as specified by the revokedauthorization, except to the extent that we have takenaction in reliance on your authorization.

Your Rights Regarding Your Health Information

You have the following rights regarding health informationwe maintain about you:

Right to Request Restrictions: You have the right torequest restrictions on how we use and disclose yourhealth information for treatment, payment or health careoperations. We are not required to agree to yourrequest. If we do agree, we will comply with yourrequest unless the information is needed to provide youemergency treatment. To request restrictions, you mustmake your request in writing and submit it to StateBusiness Administrator, 1760 E. River Rd., Suite 350,Tucson, Arizona 85718.

Right to Request Confidential Communications: You havethe right to request that we communicate with you in acertain manner or at a certain location regarding theservices you receive from us. For example, you may askthat we only contact you at work or only by mail. Torequest confidential communications, you must make yourrequest in writing and submit it to the State BusinessAdministrator, 1760 E. River Rd., Suite 350, Tucson,Arizona 85718. We will not ask you the reason for yourrequest. We will attempt to accommodate all reasonablerequests.

Right to Inspect and Copy: You have the right to inspectand copy health information that may be used to makedecisions about your care. Usually, this includes medicaland billing records, but does not include psychotherapynotes or information that is compiled in reasonableanticipation of, or use in, a civil, criminal, oradministrative action or proceeding. To inspect and copyyour health information, you must make your request inwriting by filling out the appropriate form provided by usand submitting it to the State Business Administrator,1760 E. River Rd., Suite 350, Tucson, Arizona 85718. Ifyou request a copy of your health information, we maycharge a fee for the costs of copying, mailing or preparingthe requested documents.

We may deny your request to inspect and copy in certainvery limited circumstances. If you are denied access toyour health information, you may request that the denialbe reviewed by a licensed health care professional chosenby us. The person conducting the review will not be theperson who denied your request. We will comply with theoutcome of the review.

NOTICE OF PRIVACY PRACTICES

Effective Date: 4/15/03

THIS NOTICE DESCRIBES HOW MEDICALINFORMATION ABOUT YOU MAY BE USED ANDDISCLOSED AND HOW YOU CAN GET ACCESSTO THIS INFORMATION. PLEASE REVIEW ITCAREFULLY.

About Us

In this Notice, we use terms like “we,” “us” or “our” torefer to Arizona Oncology Associates, P.C., its physicians,employees, staff and other personnel. All of the sites andlocations of Arizona Oncology Associates, P.C. follow theterms of this Notice and may share health information witheach other for treatment, payment or health care operationspurposes as described in this Notice.

Purpose of this Notice

This Notice describes how we may use and disclose yourhealth information to carry out treatment, payment orhealth care operations and for other purposes that arepermitted or required by law. This notice also outlines ourlegal duties for protecting the privacy of your healthinformation and explains your rights to have your healthinformation protected. We will create a record of theservices we provide you, and this record will include yourhealth information. We need to maintain this informationto ensure that you received quality care and to meet certainlegal requirements related to providing you care. Weunderstand that your health information is personal, andwe are committed to protecting your privacy and ensuringthat your health information is not used inappropriately.

Our Responsibilities

We are required by law to maintain the privacy of yourhealth information and provide you notice of our legalduties and privacy practices with respect to your healthinformation. We will abide by the terms of this Notice.

How We May Use or Disclose Your Health Information

The following categories describe examples of the way weuse and disclose health information:

For Treatment: We may use your health information toprovide you with medical treatment or services. Forexample, your health information will be disclosed to the

Right to Amend: If you feel that your health information isincorrect or incomplete, you may request that we amend yourinformation. You have the right to request an amendment foras long as the information is kept by or for us. To request anamendment, you must make your request in writing by fillingout the appropriate form provided by us and submitting it toState Business Administrator, 1760 E. River Rd., Suite 350,Tucson, Arizona 85718.

We may deny your request for an amendment. If this occurs,you will be notified of the reason for the denial and given theopportunity to file a written statement of disagreement with us.

Right to any Accounting of Disclosures: You have the right torequest an accounting of certain disclosures we make of yourhealth information. Please note that certain disclosures, suchas those made for treatment, payment or health care operations,need not be included in the accounting we provide to you.

To request an accounting of disclosures, you must make yourrequest in writing by filling out the appropriate form providedby us and submitting it to the State Business Administrator,1760 E. River Rd., Suite 350, Tucson, Arizona 85718. Yourrequest must state a time period which may not be longer thansix years, and which may not include dates before April 14,2003. The first accounting you request within a 12-monthperiod will be free. For additional accountings, we may chargeyou for the costs of providing the accounting. We will notifyyou of the costs involved and give you an opportunity towithdraw or modify your request before any costs have beenincurred.

Right to a Paper Copy of This Notice: You have the right to apaper copy of this Notice at any time, even if you previouslyagreed to receive this Notice electronically. To obtain a papercopy of this Notice, please contact the State BusinessAdministrator, 1760 E. River Rd., Suite 350, Tucson, Arizona85718. You may also obtain a paper copy of this Notice at ourweb site, http://www.arizonaoncology.org/who.lasso.

Right to Complain: If you have any questions about thisNotice or would like to file a complaint about our privacypractices, please direct your inquiries to: State BusinessAdministrator, 1760 E. River Rd., Suite 350, Tucson, Arizona85718. You may also file a complaint with the Secretary ofthe Department of Health and Human Services. You will notbe retaliated against or penalized for filing a complaint.

Changes to this Notice

We reserve the right to change the terms of this Notice at anytime. We reserve the right to make the new Notice provisionseffective for all health information we currently maintain, aswell as any health information we receive in the future. If wemake material or important changes to our privacy practices,we will promptly revise our Notice. We will post a copy of thecurrent Notice in all of our offices. Each version of the Noticewill have an effective date listed on the first page. Updates tothis Notice are also available at our web site,http://www.arizonaoncology.org/who.lasso.

REORDER # 03-05519

oncology nurses who participate in your care. We maydisclose your health information to another oncologistfor the purpose of a consultation. We may also discloseyour health information to your physician or anotherhealthcare provider to be sure those parties have all theinformation necessary to diagnose and treat you.

For Payment: We may use and disclose your healthinformation to others so they will pay us or reimburseyou for your treatment. For example, a bill may be sentto you, your insurance company or a third-party payer.The bill may contain information that identifies you,your diagnosis, and treatment or supplies used in thecourse of treatment.

We may share your health information withpharmaceutical company patient assistance programs andpatient support organizations in order to assist you inobtaining payment for your care or payment for certainparts of your care.

For Health Care Operations: We may use and discloseyour health information in order to support our businessactivities. For example, we may use your healthinformation for quality assessment activities, training ofmedical students, necessary credentialing, and for otheressential activities.

We may ask you to sign your name to a sign-in sheet atthe registration desk and we may call your name in thewaiting room when we call you for your appointment.

We may disclose your health information to a third partythat performs services, such as billing and collection, onour behalf. In these cases, we will enter into a writtenagreement with the third party to ensure they protect theprivacy of your health information.

Appointment Reminders: We may use and disclose yourhealth information in order to contact you and remindyou of an upcoming appointment for treatment or healthcare services.

Treatment Alternatives and Health-Related Benefits andServices: We may use your health information to informyou of services or programs that we believe would bebeneficial to you. We may call, mail or email youinformation about these services or goods. For example,we may contact you to make you aware of new products,supply product information, or a new patient assistanceprogram that may be available to you.

Fundraising Activities: We may use your demographicinformation, such as name, address and phone number,and the dates you received services from us, to contactyou in an effort to raise money for charitable purposes.We may also disclose this information to a foundationrelated to the practice so that the foundation may contactyou to raise money for the foundation. If you do notwant the practice or foundation to contact you forfundraising activities, please notify the State BusinessAdministrator, 1760 E. River Rd., Suite 350, Tucson,Arizona 85718.

Individuals Involved in Your Care or Payment for Your Care:We may release your health information, includinginformation about your condition, to a family member orfriend who is involved in your medical care or who helps payfor your care. If you would like us to refrain from releasingyour health information to a family member or friend,please notify the State Business Administrator, 1760 E.River Rd., Suite 350, Tucson, Arizona 85718. We may alsodisclose your health information to disaster-relieforganizations so that your family can be notified about yourcondition, status and location.

We are also allowed by law to use and disclose your healthinformation without your authorization for the followingpurposes:

As Required by Law: We may use and disclose your healthinformation when required to do so by federal, state or locallaw.

Judicial and Administrative Proceedings: If you are involvedin a legal proceeding, we may disclose your healthinformation in response to a court or administrative order. Wemay also release your health information in response to asubpoena, discovery request, or other lawful process bysomeone else involved in the dispute, but only if efforts havebeen made to tell you about the request or to obtain an orderprotecting information requested.

Health Oversight Activities: We may use and disclose yourhealth information to health oversight agencies for activitiesauthorized by law. These oversight activities are necessary forthe government to monitor the health care system, governmentbenefit programs, compliance with government regulatoryprograms, and compliance with civil rights laws.

Law Enforcement: We may disclose your health information,within limitations, to law enforcement officials for severaldifferent purposes:

• To comply with a court order, warrant, subpoena, summons, or other similar process;

• To identify or locate a suspect, fugitive, material witness, or missing person;

• About the victim of a crime, if unable to obtain the victim’s agreement;

• About a death we suspect may have resulted from criminal conduct;

• About criminal conduct we believe in good faith to have occurred on our premises; and

• To report a crime, the location of a crime and the identity, description and location of the individual who committed the crime, in an emergency situation.

Public Health Activities: We may use and disclose your healthinformation for public health activities, including thefollowing:

• To prevent or control disease, injury, or disability;• To report births or deaths;• To report child abuse or neglect;• To report adverse events, product defects or problems;• To track FDA-regulated products;• To notify people and enable product recalls; and• To notify a person who may have been exposed to a

communicable disease or may be at risk for contracting or spreading a disease or condition.

Serious Threat to Health or Safety: If there is a serious threatto your health and safety or the health and safety of thepublic or another person, we may use and disclose yourhealth information to someone able to help prevent the threat.

Organ/Tissue Donation: If you are an organ donor, we mayuse and disclose your health information to organizations thathandle organ procurement or organ, eye, or tissuetransplantation or to an organ donation bank.

Coroners, Medical Examiners, and Funeral Directors: Wemay use and disclose health information to a coroner ormedical examiner. This disclosure may be necessary toidentify a deceased person or determine the cause of death.We may also disclose health information, as necessary, tofuneral directors to assist them in performing their duties.

Workers’ Compensation: We may disclose your healthinformation for workers’ compensation or similar programs.These programs provide benefits for work-related injuries orillness.

Victims of Abuse, Neglect or Domestic Violence: We maydisclose health information to the appropriate governmentauthority if we believe a patient has been the victim of abuse,neglect, or domestic violence. We will only make thisdisclosure if you agree, or when required or authorized bylaw.

Military and Veterans Activities: If you are a member of theArmed Forces, we may disclose your health information tomilitary command authorities. Health information aboutforeign military personnel may be disclosed to foreignmilitary authorities.

National Security and Intelligence Activities: We maydisclose your health information to authorized federalofficials for intelligence, counterintelligence, and othernational security activities authorized by law.

Protective Services for the President and Others: We maydisclose your health information to authorized federalofficials so they may provide protective services for thePresident and others, including foreign heads of state.

Inmates: If you are an inmate of a correctional institution orunder the custody of a law enforcement official, we maydisclose your health information to the correctional institutionor law enforcement official to assist them in providing youhealth care, protecting your health and safety or the healthand safety of others, or for the safety of the correctionalinstitution.

Research: We may use and disclose your health informationfor certain limited research purposes. All research projects,however, are subject to a special approval process. Thisprocess evaluates a proposed research project, assesses anumber of specific issues, and determines that appropriateprivacy safeguards are in place to allow the use of healthinformation in the research project. We may, however,disclose your health information to people preparing toconduct a research project; for example, to help them look forpatients with specific medical needs, so long as the healthinformation they review does not leave the practice.

Radiation New Patient Packet - Arizona Oncology

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