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Patient Referral

To expedite the scheduling process, we will need the following documents:

  • A recent signed office note with the patient’s height, weight, LCD approved ICD-10 diagnosis code.
  • Drug order form that is signed and dated.
  • Copy of the front and back of the patient’s insurance and prescription cards.
  • Any labs: CBC, CMP, and any additional listed on drug order form.

Let’s get started.

Scheduling
Tell us about your intent.
Who is filling this out?
Legal Representative's Name
Legal Representative's Name
First Name
Last Name
Primary Treatment Type Requesting
Tell us more about the patient's primary diagnosis or concern.
Medical Records Release Authorization

Patient Records

Select the information that you give permission to release
Confirmation
Confirmation

Submit Records

Maximum file size: 100MB

Files needed: Signed Office Note with Height Weight, LCD Approved ICD-10 diagnosis code. Drug order form that is signed and dated. Copy of insurance prior authorization. Front and back copy of insurance and Rx cards. Any CBC, CMP or other order forms.
Select all the documents below that you are UNABLE to provide
NECS NPI: 1205896107 NECS Tax ID: 10357684

Patient Information

Name
Name
First Name
Last Name
Birth Sex
Address
Address
City
State/Province
Zip/Postal
Patient's Primary Language
Patient's Race
Patient's Ethnicity
Select all that apply
Does patient have a primary care physician?

Primary Care Provider

Name
Name
First Name
Last Name
Does patient have an oncologist?

Oncologist's Information

Name
Name
First Name
Last Name
Does patient have insurance?

Patient Insurance

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Non-oncology Infusion

Blood Cancer

Benign Blood Condition

Breast Cancer

Breast Surgery

Select all breast conditions that apply.
Any prior breast procedures?
Do you have a surgeon preference?

GI Cancer

Genitourinary Cancer

Gynecologic Cancer

Head and Neck Cancer

Lung Cancer

Skin Cancer

Radiation Therapy

Genetic and Hereditary Screenings

What is the urgency level?
Is there a need for genetic testing?

Referring Practice Information

Office Contact
Office Contact
First Name
Last Name
Which is more important?
Select a location preference
Select a Physician

Authorization to Treat

Consent for Treatment - I authorize New England Cancer Specialists (NECS), its physicians, employees, agents, independent physicians, and contractors to diagnose, treat and care for me.

• I understand and accept that CT Technologists, Radiologists, and some Nutritionists and Medical Assistants are contracted, and not employees or agents of the practice.

• I consent to examinations, tests, treatments, immunizations, medications, photo-documentation and other treatments or procedures determined to be beneficial. I agree to review and sign any informed consent documents for specific treatment that may be required by state law. I consent to having my picture taken as part of my health record for the use of patient identification.

• I understand I may be transferred or referred to another health care provider or facility, for my care and treatment.

• I understand that I have the right to refuse all or part of care provided to me.

Assignment of payments and guarantee of payment - I authorize and direct my health insurance carrier(s) or other third parties who are responsible for paying my health care to pay the costs associated with my treatment and care directly to NECS. I guarantee full payment of charges not covered or paid by my health insurance within 90 days, including co-payments or deductibles, collection costs and attorney's fees. If I am unable to pay, I agree to complete a detailed financial statement to make alternative arrangements for full payment.

Consent to Use and Disclosure of Protected Health Information - I consent to NECS and its affiliates use and disclosure of my protected health information (PHI) in support of my diagnosis and treatment, payment for the medical services I receive, and the legitimate health care operations of the medical practice.

I consent to NECS' and its affiliates' disclosure of PHI to other healthcare practitioners and facilities that are involved in

providing medical services to me. In addition, I consent to NECS' and its affiliates' disclosure of PHI to my health insurance carrier, utilization review organization, or third-party administrator to support payment for my medical services.

I understand that NECS and its affiliates including independent and contracted professionals agree to provide medical services to me is conditional upon my signing of this consent form.

I understand that NECS and its affiliates will access my external prescription history for the purpose of facilitating my care.

I understand that NECS and its affiliates will disclose only the minimum amount of health care information necessary, in the judgment of NECS and all of its affiliates, for the legitimate needs of the recipient or for my general well-being.

I understand my PHI, which is the subject of this consent, includes demographic information; information about my physical or mental health condition; medication/prescription history; information about the medical services provided to me, including my payment information, if any of that information may be used to identify me. [Depending upon the medical services I request or require, this information may include information about treatments of HIV/AIDS, mental health or psychiatric conditions, substance abuse, or genetic information including test results.]

I understand that I have the right to restrict NECS and its affiliates use and disclosure of my PHI and NECS and its affiliates are not obligated to agree to the requested restrictions, but that an agreement to a restriction binds NECS and its affiliates. I may revoke this consent at any time providing NECS and its affiliates with a written, signed and dated request except to the extent that NECS and its affiliates have acted in reliance upon my consent. However, I understand that any restriction on the use and disclosure of PHI or revocation of this consent may result in improper diagnosis or treatment, denial of coverage of a claim for insurance benefits, or other adverse consequences.

I acknowledge this consent will remain in effect for all subsequent uses and disclosures for the limited purposes outlined above for 30 months from the date of this consent, unless I revoke it earlier, as described above.

I understand that NECS and its affiliates regard the safeguarding of PHI to be important. I understand, furthermore, that the elements of this consent are required by state and federal law for my protection and to ensure my informed consent to the use and disclosure of PHI necessary to support my relationship with NECS and its affiliates.

Do you give us permission to leave messages on your voicemail.
Notice of Privacy: I have received a copy of NECS Notice of Privacy Practices & Patient Rights and Responsibilities which provides a more complete description of the uses and disclosures addressed above, including disclosure of my PHI by NECS or its affiliates to a state-wide health information exchange designed to facilitate rapid access to my PHI for quality treatment purposes. I acknowledge that NECS reserves the right to amend the Notice of Privacy Practices periodically. I understand that I may obtain a copy of the Notice by contacting the office staff or my physician, at any time.
I consent to being contacted, using contact information provided to the practice, including email address or cell phone number, with questions regarding my care or by representatives of NECS to assess my experience as a patient. I also consent to receive periodic emails from NECS to communicate practice news, updates, events, and other services that may be of benefit to me. I understand that I can unsubscribe to these emails at any time.
I understand, if I have a question about this consent or about NECS' and its affiliates' privacy practices, or if I want to have a copy of this consent, I may ask the office staff or my physician.
Are any of these social determinants a concern?
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