New Patient Forms

NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY.

YOUR RIGHTS: When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

1.     Your Health Information Is Private

a. Keeping your health information private is one of our most important responsibilities. We are committed to protecting your health information and following all laws regarding the use of it.

b. We will let you know promptly if a breach of your privacy were to ever occur that may have compromised your privacy or security of your information.

2.     Who Sees and Shares My Health Information?

a. Your private health information may be used by healthcare providers such as physicians, nurses, therapists, or social workers who care for you.

b. We will not use or share your information other than described here unless you tell us we can in writing.

3.     Get an Electronic or Paper Copy of Your Medical Record

a. You can ask to see or receive an electronic or paper copy of your medical record and information. We will provide a copy or a summary of your health information as soon as possible. We may charge a reasonable, cost-based fee.

4.     Ask Us to Correct Your Medical Record

a. You can ask us to correct your health information that you think is inaccurate or incomplete.

5.     Request Confidential Communications

a. You can ask us to contact you in a specific way (e.g., phone, email, or regular mail).

6.     Ask Us to Limit What We Share and Use

a. You can ask us not to use or share certain health information for treatment, payment, or our operations.

7.     Get a List of Those With Whom We’ve Shared Information

a. You can ask for a list of the times we’ve shared your information for six years prior to the date you ask, who we’ve shared it with, and why. We will include all the disclosures except for those about treatment, payment, and healthcare operations.

8.     Get a Copy of This Privacy Notice

a. You can ask for a copy of this notice at any time. We will provide you with a paper copy promptly.

9.     Choose Someone to Act for You

a. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

b. We will make sure the person has the authority and can act for you before we take any action.

10. File a Complaint if You Feel Your Rights Are Violated

a. You can complain if you feel we have violated your rights by contacting our compliance office. We will not retaliate against you for filing a complaint.

YOUR CHOICES: For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, tell us what you want us to do and we will follow your instructions.

1.     In These Cases, You Have Both the Right and Choice to Tell Us to Share or Withhold Information

a. Share information with your family, friends, or others involved in your care.

b. Share information in a disaster relief situation.

c. Include your information in a patient directory.

2.     In These Cases We May Never Share Your Information Unless You Give Us Written Permission

a. Marketing purposes.

b. Sale of your information.

c. Most sharing of psychotherapy notes.

OUR USES AND DISCLOSURES: We are allowed or required to share your health information in the following ways:

1.     To Treat You

a. We can use your health information and share it with other health professionals treating you.

2.     To Run Our Organization

a. We can use and share your health information to run our practice, improve your care, and contact you when necessary.

3.     To Bill for Your Services

a. We can use and share your health information to bill and get payment from health plans.

4.     To Help With Public Safety

a. We can share your health information to prevent disease pandemics; help with product recalls; report suspected abuse, neglect, or domestic violence; or prevent a serious threat to someone’s safety.

5.     To Comply With the Law

a. We will share health information if required by state or federal law.

6.     To Respond to Lawsuits and Legal Actions

a. We can share health information in response to a court or administrative order, or in response to a subpoena.

Questions or complaints? If you have any questions about this notice, or you think that we have not protected your private health information and you wish to complain about it, please contact any of the following:

The Oncology Institute of Hope and Innovation

Compliance Officer: Mark Hueppelsheuser

OR

Office for Civil Rights

U.S. Department of Health and Human Services

200 Independence Avenue, S.W.

Room 509F, HHH Building

Washington D.C. 20201-0004

Or by calling the office for Civil Rights at (800) 368-1019
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
Patient Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
By signing this form,

I acknowledge that I have received a copy of the Notice of Privacy Practices of The Oncology Institute of Hope and Innovation.
Signature *

Clear
Date *

Month Day Year
Date
If signed by Patient's Personal Representative:
Print Name
Signature

Clear

NEW PATIENT FORM
Patient Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Mobile Phone *
Home Phone *
Opt-in to receive text alerts
Email *
example@example.com
Opt-in to receive email alerts and newsletter
Sex: Male or Female *
Date of Birth *

Month Day Year
Date
Social Security # *
Employer Name
Employer Phone
Employer Address
Spouse/Contact Name
Spouse/Contact Phone
Spouse/Contact Address
Primary Insurance *
Primary Insurance Phone *
Subscriber ID *
Group # *
Secondary Insurance
Secondary Insurance Phone
Subscriber ID
Group #
Emergency Contact *
Emergency Contact Phone *
Relationship to Patient *
Name of Referring Physican *
Referring Physician Phone *
Name of Primary Care Physician *
Primary Care Physician Phone *
The undersigned has insurance coverage with Insurance Company Name and assigns directly to The Oncology Institute of Hope and Innovation 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 or not they are paid by the insurance. I hereby authorize The Oncology Institute of Hope and Innovation to release all information necessary to secure the payment of benefits and further authorize the use of the signature on all insurance benefits.

HIPPA PRIVACY – AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
I First Name * Last Name * Date of Birth Social Security # Address (Street, City, Zip) Phone Number Hereby Authorize Name of Provider
To release 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 purpose 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 l do not sign this authorization.

I declare under penalty of perjury that the information on this form is true and correct.
Signature *

Clear
Date *

Month Day Year
Date

CO-PAY AND COINSURANCE POLICY
To our valued patients and families:

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.

By signing below, I acknowledge and agree to the policy stated herein.
Patient Name *

First Name Last Name
Signature *

Clear
Date *

Month Day Year
Date

PATIENT RIGHTS AND RESPONSIBILITIES
PURPOSE: To describe the patient’s rights and responsibilities

SCOPE: Dispensary staff, patients

POLICY: The Oncology Institute of Hope and Innovation's dispensary customers have a right to be notified of their rights and obligations before care/service is begun. If the patient cannot read the statement of rights and responsibilities, it shall be given to the patient in a language they can understand. This information can also be found on company website www.theoncologyinstitute.com/your-first-visit/ under New Patient Packet. The Oncology Institute will provide paper copies to patients without access to the website or who request a paper copy. The Oncology Institute has an obligation to protect and promote the rights of their customers to care, treatment, and services within their capability and mission, and in compliance with applicable laws, regulations, and standards, including the following:

YOU HAVE THE RIGHT TO:

• Be fully informed in advance about services/care to be provided, including the company representatives that provide care/services, and the frequency of visits as well as any modifications to the service/care plan.

• Be treated, and have your property treated, with dignity, courtesy and respect, recognizing that each person is a unique individual.

• Be informed both orally and in writing, in advance of care being provided of the charges, including payment for care/services expected from third parties and any charges for which the patient will be responsible.

• Receive information about the scope of services that the organization will provide and specific limitations on those services.

• Participate in the development and revision of the plan of care.

• Refuse care or treatment after the consequences of refusing care or treatment are fully presented.

• Be free from mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property.

• Voice grievances/complaints regarding treatment of care, lack of respect of property, or recommend changes in policy, personnel, or services without restraint, interference, coercion, discrimination, or reprisal.

• Have complaints regarding treatment or care, or lack of respect of property investigated.

• Confidentiality and privacy of all information contained in the patient record and of protected health information.

• Be advised on agency’s policies and procedures regarding the disclosure of clinical records.

• Choose a health care provider.

• Receive appropriate care without discrimination in accordance with physician orders.

• Be informed of any financial benefits when referred to an organization.

• Be fully informed of one’s responsibilities.

CUSTOMER RESPONSIBILITIES: DRX2-2A.01

You have the responsibility to:

• Adhere to the plan of treatment or service established by your physician.

• Adhere to the company’s policies and procedures.

• To submit any forms that are necessary to participate in the program, to the extent required by law.

• Participate in the development of an effective plan of care/treatment/services.

• Provide, to the best of your knowledge, accurate and complete medical and personal information necessary to plan and provide care/services.

• Provide any necessary forms and documentation needed to participate in patient management programs, to the extent required by law.

• Ask questions about your care, treatment and/or services, or to have clarified any instructions provided by company representatives.

• Communicate any information, concerns and/or questions related to perceived risks in your services, and unexpected changes in your condition.

• Be available at the time deliveries are made and to allow The Oncology Institute’s representatives to enter your residence at reasonable times to repair or exchange equipment or to provide services.

• Notify the company if you are going to be unavailable.

• Treat company personnel with respect and dignity without discrimination as to color, religion, sex, or national or ethnic origin.

• Provide a safe environment for dispensary representatives to provide services.

• Care for and safely use medications, supplies and/or equipment, according to instructions provided, for the purpose it was prescribed and only for/on the individual for whom it was prescribed.

• Communicate any concerns about your/your caregiver’s/your family member’s ability to follow instructions or use the equipment provided.

• Protect equipment from fire, water, theft, or other damage. You agree not to transfer or allow your equipment to be used by any other person without prior written consent of the company and further agree not to modify or attempt to make repairs of any kind to the equipment. Modifying equipment or attempting equipment repairs releases the company from any liability related to the equipment and its uses, and from any resulting negative customer outcomes.

• Except where contrary to federal or state law, you are responsible for equipment rental and sale charges that your insurance company or companies do not pay. You are responsible for prompt settlement in full of your accounts unless prior arrangements have been approved by company administration.

• The company should be notified of any changes in your physical condition, physician’s prescription, or insurance coverage. Notify the company immediately of any address or telephone changes, whether temporary or permanent.

GRIEVANCES AND COMPLAINTS

You have the right to raise complaints with the dispensary verbally or in writing by contacting any one of the parties below:

o Jeffrey Muralles – Dispensary Manager (jeffreymuralles@theoncologyinstitute.com)

o Mark Hueppelsheuser – Compliance Officer (markhueppelsheuser@theoncologyinstitute.com)

o ACHC – Credentialing Organization (855-937-2242)

ACKNOWLEDGEMENT OF NEW PATIENT PACKET
I First Name* Last Name* acknowledge that I have received, read, and understand The Oncology Institute’s New Patient Packet including but not limited to HIPPA privacy policies, patient rights and responsibilities, advanced directive, copay policies, and general dispensary information.
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

NOTICE OF PRIVACY PRACTICES

NEW PATIENT FORM

HIPPA PRIVACY – AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

CO-PAY AND COINSURANCE POLICY

MY ADVANCED DIRECTIVE AND GOALS FOR CARE

PATIENT RIGHTS AND RESPONSIBILITIES

ACKNOWLEDGEMENT OF NEW PATIENT PACKET