• DateTime
  • Do you consent to receive text appointment reminders & information about your health care treatment?*
  • Date of Birth*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Did you know Peninsula Radiation Oncology Center was in Soldotna before you were referred?*
  • Where else have you heard about Peninsula Radiation Oncology Center (check all that apply)*

  • Providers

    Please indicate your providers below:
  • Medications (put N/A in the first cell if no medication)*
    Rows
  • Allergy*
    Rows
  • Allergy to Medications or IV Contrast*
    Rows

  • Medical History

    Check all that apply
  • Brain | Cognitive | Psychologic*
  • Lung | Respiratory | Cardiac*
  • Stomach | Intestinal | Digestive*
  • Blood | Hepatic | Circulation*
  • Bladder | Kidney | Urologic*
  • Miscellaneous*
  • Do you have a prior history of cancer?*
  • Have you had prior radiation therapy?*
  • Have you had prior chemotherapy?*
  • Do you have a pacemaker or defibrillator?*
  • Are you pregnant or do you want to have more children?*
  • Surgeries or Recent Hospitalizations (put N/A in the first cell if not applicable)*
    Rows
  • Family Cancer History*
    Rows

  • Social History

  • Which best describes your employment status?*
  • Exposure to hazardous materials?*
  • Do you drink alcohol?*
  • Do you smoke cigarettes?*
  • Have you ever smoked cigarettes?
  • Cigarette History*
    Rows
  • Other tobacco products (check all that apply)*
  • Do you concerns about any of the following?*

  • Current Symptoms

    Check all that apply
  • *
  • *
  • Are you in pain?*

  • HIPAA Notice of Privacy Practices

    THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

  • I authorize you to give me reasonable and proper medical care by today’s standards. All professional services rendered are charged to the patient, and necessary forms will be completed to help expedite insurance carrier payments. However, the patient is responsible for fees, regardless of insurance coverage. It is also customary to pay for services when rendered unless other arrangements have been made in advance with Peninsula Radiation Oncology Center.


    I request payment of authorized Medicare/Other Insurance company benefits be made on my behalf to Peninsula Radiation Oncology Center, for any services furnished me by that party who accepts assignment/physician. Regulations pertaining to Medicare assignment of benefits apply.


    I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carrier or any other insurance company any information needed for this or a related Medicare/Other Insurance company claim.


    I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. In Medicare /Other Insurance Company assigned cases, the physician agrees to accept the charge determination of the Medicare/Other Insurance Company as the full charge, and the patient is responsible only for the deductible coinsurance, and non-covered services. Coinsurance and the deductible are based upon the charge determination of the Insurance Company.

  • Receipt of HIPAA Information

    We are required by law to maintain the privacy of and provide individuals with this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer at (907) 262-7762. Signature below is acknowledgement that you have received this Notice of our Privacy Practices.

  • Authorizations for Release of Health Information

    Please answer the following three questions regarding the release and disclosure of your medical and billing information.
  • Do we, Peninsula Radiation Oncology Center, have your permission to release your medical information to ALL of your healthcare providers and insurance companies?*
  • Do we, Peninsula Radiation Oncology Center, have your permission to obtain your medical information to ALL of your healthcare providers and insurance companies?*
  • Please list ALL family member(s)/guardian(s) that Peninsula Radiation Oncology Staff or physicians may speak with regarding your Care, Medical records, Financial, and/or Billing information. Please list ALL:
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  • I have the right to revoke this authorization at any time. My revocation must be in writing, signed by me or my legal representative, and delivered to Peninsula Radiation Oncology Center, Attn: HIPAA Compliance Officer, via mail or in person. It will be effective only when Peninsula Radiation Oncology Center physically receives it. The information that is disclosed under this authorization may be disclosed again by the person or organization to which it is sent. The privacy of this information may not be protected under federal privacy regulations.

    Please note, this form expires one year after signed. You will be asked to complete this form annually.

  • Care Consent & Financial Policy

  • I authorize you to give me reasonable and proper medical care by today’s standards. All professional services rendered are charged to the patient, and necessary forms will be completed to help expedite insurance carrier payments. However, the patient is responsible for fees, regardless of insurance coverage. It is also customary to pay for services when rendered unless other arrangements have been made in advance with Peninsula Radiation Oncology Center.


    I request payment of authorized Medicare/Other Insurance company benefits be made on my behalf to Peninsula Radiation Oncology Center, for any services furnished me by that party who accepts assignment/physician. Regulations pertaining to Medicare assignment of benefits apply.


    I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carrier or any other insurance company any information needed for this or a related Medicare/Other Insurance company claim.


    I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. In Medicare /Other Insurance Company assigned cases, the physician agrees to accept the charge determination of the Medicare/Other Insurance Company as the full charge, and the patient is responsible only for the deductible coinsurance, and non-covered services. Coinsurance and the deductible are based upon the charge determination of the Insurance Company.

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