NEOK Patient Intake - Updated 2025

DateTime
Patient Intake Form
Name*

First NameLast Name
Preferred Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender*
SSN*
Date of Birth*

MonthDayYear
Date
Age*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
May we leave a message on your voicemail?*

YesNo
May we text appointment reminders?*

YesNo
Referring Provider
Primary Care Provider*
Preferred Pharmacy*
Medical Oncologist
Other Providers

Emergency Contacts (please provide 2)*

	Name	Relationship	Phone Number
Emergency Contact
Emergency Contact

Before your referral were you aware of a cancer center in Claremore?*

YesNo
How had you heard about Northeastern Oklahoma Cancer Institute Claremore? Check all that apply

Radio adsWebsiteCommercialFacebookOther

Please check 'yes' if you have seen any of the following specialists:*

	Yes
Radiation Oncologist
Medical Oncologist
Surgeon
None of these

Have you ever had any of the following?*

	Yes
Prior Cancers
Prior Radiation
Prior Chemotherapy
None of these

If you've had cancer before, where was your prior cancer treatment and when
Do you have a pacemaker or defibrillator? (if yes, please provide us with a copy of your pacemaker information)*

YesNo

	Tobacco Use
How many packs per day
What age started
What age stopped

	Yes or No
Do you have an Advance Directive?
Do you have a Do Not Resuscitate / Do Not Intubate Directive?

	Experiencing Symptom
Cataracts
Double vision
Changes in vision
Other vision problems
None

	Experiencing Symptom
Loss of hearing
Nose bleeds
Dental problems
Hoarseness
Difficulty swallowing
Neck pain or swelling
Other symptoms
None

	Experiencing Symptom
Shortness of breath
Coughing
Coughing up blood
Oxygen use at home
Other
None

	Experiencing Symptom
Pacemaker
Chest pain
Irregular heartbeat
Palpitations
Fainting spells
Leg pain while walking
Other
None

	Experiencing Symptom
Heartburn
Nausea
Abdominal pain
Blood in stool
Other
None

	Experiencing Symptom
Difficulty urinating
Blood in urine
Other
None

	GYN Answers
Age of first menstrual cycle
# of pregnancies
# of live births
Did you breastfeed?
Age of menopause
Have you had hormone replacement therapy?
Do you use Birth Control Pills?

	Experiencing Symptom
Joint Pain
Muscle weakness
Physical disabilities
Other
None

	Experiencing Symptom
Rash
Sores
Growths
None

	Experiencing Symptom
Headaches
Tremors
Numbness or tingling
Dizziness
Loss of consciousness
Seizures
Unsteady gait
Other
None

	Experiencing Symptom
Anxiety
Depression
Other
None

	Experiencing Symptom
Hot Flashes
Other
None

	Experiencing Symptom
Swollen Lymph Glands
Excessive bruising and bleeding
Other
None

Patient Financial Responsibility Agreement

At Northeastern Oklahoma Cancer Institute, we truly appreciate the opportunity to provide you with compassionate, state-of-the-art care. This Agreement identifies your financial obligations for all the services you receive from us, including the services provided today and in the future. Please let us know if you do not understand any of the items discussed in this agreement.

• Please inform us of ALL insurance coverage you possess, and of any recent changes. This is crucial for proper billing and to ensure insurance coverage for our services, when available. We need correct and current information on a timely basis. If your insurance coverage changes, please contact our office immediately at 918-283-4078.
• If you do not have insurance, a payment plan can be established via our business office.
• At your request, a financial counselor can provide you with an estimate of your financial responsibility for your treatment. However, please understand that an estimate is not binding and that the actual cost may be different. You are personally responsible to us for the full payment of all services you receive from us. Our business office accepts payment for daily co-pays via cash, check, or credit card.
• We will submit a claim to your primary and secondary insurance for all services that we provide to you. If we do not receive payment within 30 days of submission or your insurance notifies us that you are not covered under your insurance plan (e.g. the services were not pre-authorized), you will pay us the outstanding balance of the services. We will send you a statement for the amount due. If your account, including reasonable attorneys’ fees and collection costs. If we eventually receive a payment from your primary or secondary insurance, we will refund the difference to you.
• You authorize and direct any insurance proceeds payable for services provided by us to you to be paid directly to us, and assign to us, without recourse, all interest in and rights to claim, collect and receive the proceeds from any insurance company providing coverage for our services. You authorize any insurance company to furnish to use and our agents all information pertaining to your insurance benefits and the status of all claims submitted by us.
• We are Medicare providers and accept assignment from Medicare. However, there may be a balance due from you after Medicare pays. Medicare law prohibits us from waiving this balance.
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Notification of Disclosure to Persons Involved in Your Case & Emergency Contacts
Unless you specifically agree, we will not disclose any information to family or other persons involved in your care either by phone or in person. This means, for example, that we will not be able to answer questions about your radiation treatments, medications, prescriptions, billing, schedule appointments or otherwise discuss any aspect of your care or treatment with anyone other than you. If you would like us to be able to discuss information related to your care with specific persons, please list those persons below.

I hereby authorize Northeastern Oklahoma Cancer Institute to discuss all aspects of my treatments with the above listed persons.

Individuals for Disclosure

	Name & Phone Number	Relationship to Patient
1
2
3
4
5
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8
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Patient Comments
I hereby authorize Northeastern Oklahoma Cancer Institute to discuss all aspects of my treatments with the above listed persons.

Clear

CANCER INSTITUTE
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

Uses and Disclosures
Treatment. Your health information may be used by our staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of tests and procedures will be available in your medical record for all health professionals who may provide treatment or who may be consulted by our staff members.

Payment. Your health information may be used to see payment from your health insurance plan, from other sources of coverage, or from credit card companies that you may use for payment of services. For example, your health plan may request and receive information on dates of service, the services provided, and the medical condition being treated.

Health Care Operations. Your health information may be used as necessary to support the day-to-day activities and management of Southeast Radiation Oncology. For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality.

Public Health Reporting. Your information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state’s public health department.

Other uses and disclosures require your authorization. Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a disclosure of your information, you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use of disclosure of information that occurred prior to your notification of your decision to us.

Appointment reminders. Your health information may be used by our staff to send you appointment reminders.

Individual Rights

You have certain rights under the federal privacy standards. These include:
• The right to request instructions on the use and disclosure of your protected health information
• The right to receive confidential communications concerning your medical condition and treatment
• The right to inspect and copy your protected health information
• The right to amend and or submit corrections to our protected health information
• The right to receive an accounting of how and to whom your protected health information has been disclosed
• The right to receive a printed copy of this notice

Northeastern Oklahoma Cancer Institute’s Duties:
We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices.
We are also required to abide by the privacy privileges and practices that are outlined in this notice.

Right to Revise Privacy Practices
As permitted by law, we reserve the right to amend or modify our privacy practices. These changes in our policy and practices may be required in federal and state laws and regulations. Whatever the reason for the revisions, we will provide you with a revised notice on your next office visit. The revised policies and practices will be applied to all protected health information that we maintain.

Requests to Inspect Protected Health Information
As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records by contacting our front office coordinator.

Complaints
If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concern to the contact person listed below.

If you believe that your privacy rights have been violated, you should call the matter to the attention by sending a letter describing the cause of your concern to the same address.

You will not be penalized or otherwise retaliated for filing a complaint.

Contact Person
The name and address of the person that you may contact for further information concerning our privacy practice is:
Manager
Northeastern Oklahoma Cancer Institute
1501 N Florence Ave Ste 191
Claremore, OK 74017

Your signature is an acknowledgment of receipt that you have read the Notice of Privacy Practices. If you request a copy of your notice, it will be provided.
Northeastern Oklahoma Cancer Institute's Duties:

We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices. We are also required to abide by the privacy privileges and practices that are outlined in this notice. Right to Revise Privacy Practices As permitted by law, we reserve the right to amend or modify our privacy practices. These changes in our policy and practices may be required in federal and state laws and regulations. Whatever the reason for the revisions, we will provide you with a revised notice on your next office visit. The revised policies and practices will be applied to all protected health information that we maintain. Requests to Inspect Protected Health Information As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records by contacting our front office coordinator.

Complaints If you would like to submit a comment or complaint about our privacy practices, you can do SO by sending a letter outlining your concern to the contact person listed below. If you believe that your privacy rights have been violated, you should call the matter to the attention by sending aletter describing the cause of your concern to the same address. You will not be penalized or otherwise retaliated for filing a complaint.

The name and address of the person that you may contact for further information concerning our privacy practice is:

Manager Northeastern Oklahoma Cancer Institute 1501 N Florence Ave Ste 191 Claremore, OK 74017

Your signature is an acknowledgement of receipt that you have read the Notice of Privacy Practices. If you request a copy of your notice, it will be provided.
Sign Here

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Authorization to Obtain Medical Records
I understand that:

1. I may refuse to sign this authorization and that it is strictly voluntary.
2. My treatment, payment, enrollment or eligibility for benefits may not be conditioned on signing this authorization.
3. I may revoke this authorization at any time in writing, but if I do, it will not have any affect on any actions taken prior to receiving the
revocation. Further details may be found in the Notice of Privacy Practices.
4. If the requester or receiver is not a health plan or health care provider, the released information may no longer be protected by federal
privacy regulations and may be redisclosed.
5. I understand that I may see and obtain a copy the information described on this form, for a reasonable copy fee, if I ask for it.
6. I get a copy of this form after I sign it.
Signature

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Should be Empty:

	Had Cancer?	Type of Cancer
Mother
Father
Sister
Brother
Children
Maternal Grandmother
Maternal Grandfather
Maternal Aunt
Maternal Uncle
Paternal Grandmother
Paternal Grandfather
Paternal Aunt
Paternal Uncle

	Experiencing Symptom	Amount in lbs (for weight questions only)
Recent Weight Loss
Recent Weight Gain
Loss of appetite
Fatigue
Fever of chills
None

Patient Intake Form

SOCIAL HISTORY

WORK HISTORY

PAIN

HISTORY OF TOBACCO, ALCOHOL, AND DRUGS

ADVANCE DIRECTIVE (LIVING WILL)

REVIEW OF SYMPTOMS

Notification of Disclosure to Persons Involved in Your Case & Emergency Contacts

CANCER INSTITUTE

Authorization to Obtain Medical Records

	Past Medical History	Year of Diagnosis
1
2
3
4
5
6

	Past Surgery	Year
1
2
3
4
5
6

	Medication/Supplement	How Many Do You Take Daily?	Reason for Taking Medication/Supplement
1
2
3
4
5
6
7

	Allergy	Reaction
1
2
3
4