Please list when and where treatment was administered.

Please check previous immunizations received and include date of last vaccine if known.

Please list the last known date of any following screenings.

Check all that apply or check none.

To the best of my knowledge, all of this information is true and correct. I understand that I am responsible to pay for all services rendered to me and that I am willing to make specific arrangements to pay what is not covered by insurance on a timely basis. (PLEASE REMEMBER THAT INSURANCE IS CONSIDERED A METHOD OF REIMBURSING THE PATIENT FOR FEES PAID TO THE DOCTOR AND IS NOT A SUBSTITUTE FOR PAYMENT.) I grant permission to my physician to mutually exchange medical information with my referring physician(s) and/or their associates. To the extent necessary to determine liability for payment and to obtain reimbursement, I authorize disclosure of portions of the patient’s medical record to my insurance and Medi-gap carriers. If this account is assigned to an attorney for collections and/or suit, the prevailing party shall be entitled to reasonable attorney’s fees and cost of collection. I hereby assign all medical benefits to which I am entitled to my physician for services rendered to me or my dependent. This assignment will remain In effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original.

I request that payment of authorized Medicare, Medicaid, and/or other insurance benefits be made directly to HIGHLANDS ONCOLOGY GROUP for any service provided to me by HIGHLANDS ONCOLOGY GROUP. I authorize HIGHLAND ONCOLOGY GROUP to release information to HCFA and its agents any information needed to determine benefits.