Patient Referral

Tell us about yourself

New Patient - New Diagnosis

New Patient - Second Opinion

Referring practice

Primary Treatment Type Requesting

See Medical Oncologist or Hematologist

Breast Surgery

Radiation Therapy

Non-Oncology Infusion

Tell us more about the patient's primary diagnosis or concern.

Medical Records Release Authorization

I authorize New England Cancer Specialists to obtain my medical records from other healthcare providers for the purpose of providing medical care to me.

Do not authorize the release of health information.

Patient Records

I grant permission to share my health information received as early as:

Until:

Select the information that you give permission to release

Alcohol or drug dependency records

HIV / AIDS Antibody Test Results and Diagnosis/Treatment Records

Mental Health Treatment Records - Specific diagnosis

Genetic Information (Including Genetic Test Results)

Confirmation

I understand that once this information is released, my physician and/or their employees cannot prevent the re-disclosure of that information. I release New England Cancer Specialists and any of its employees from any and all liability arising directly from disclosure authorized by this consent and any re-disclosure of that information.

Confirmation

I understand I have the right to revoke this authorization at any time. Authorization will be considered inactive when New England Cancer Specialists receives a request in writing to revoke authorization.

Patient's Signature

Clear

Submit Records

Upload Any Records You Have

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

Do not have most recent signed office note with height, weight, LCD approved ICD-10 diagnosis code.

Do not have drug order form that is signed and dates

Do not have a copy of insurance Prior Authorization with NECS as rendering provider/location

Do not have a copy of insurance card front & back (Rx Card if available).

Do not have a labs: CBC, CMP, and any additional listed on drug order form

NECS NPI: 1205896107 NECS Tax ID: 10357684

Patient Information

Name

First Name

Last Name

Date of Birth

Birth Sex

Male

Female

Email

Address

City

State/Province

Zip/Postal

Phone

Patient's Primary Language

Patient's Race

Patient's Ethnicity

Latino or Hispanic

Not Latino or Hispanic

Prefer not to answer

Unknown

Select all that apply

Patient is in a skilled nursing facility

Patient is able to walk and travel

Neither

Does patient have a primary care physician?

Yes

No

Unknown

Primary Care Provider

Name

First Name

Last Name

Practice Name

Phone

Fax

Does patient have an oncologist?

Yes

No

Unknown

Oncologist's Information

Name

First Name

Last Name

Oncology Practice Name

Phone

Fax

Does patient have insurance?

Yes

No

Patient Insurance

Insurance Carrier

Policy Number

Phone

Add Remove

Non-oncology Infusion

What medications are needed for infusion?

Blood Cancer

Benign Blood Condition

Breast Cancer

Breast Surgery

Select all breast conditions that apply.

Any prior breast procedures?

Yes

No

Where was your procedure?

Approximately when was the procedure?

Location(s) of any prior breast imaging?

Do you have a surgeon preference?

No preference

Jillian Smith, MD

Paige Teller, MD

GI Cancer

Genitourinary Cancer

Gynecologic Cancer

Head and Neck Cancer

Lung Cancer

Skin Cancer

Radiation Therapy

Genetic and Hereditary Screenings

Any additional information on diagnosis or treatment request?

What is the urgency level?

Routine (within 2-4 weeks)

Urgent (within 1 week)

STAT (within 24-48 hours (please call 207-303-3551)

Is there a need for genetic testing?

Yes

No

Referring Practice Information

Office Contact

First Name

Last Name

Office Name

Phone

Email

Fax

Office NPI Number

Tax ID

Which is more important?

Selecting a specific specialist

Getting care at a specific location

See a specialist as soon as possible

Select a location preference

Kennebunk, ME

Portsmouth, NH

Topsham, ME

Westbrook, ME

Select a Physician

Are any of these social determinants a concern?

Food Insecurity

Transportation

Finances and Bills

Lodging

Captcha

Let’s get started.

Patient Records

Submit Records

Patient Information

Primary Care Provider

Oncologist's Information

Patient Insurance

Non-oncology Infusion

Blood Cancer

Benign Blood Condition

Breast Cancer

Breast Surgery

GI Cancer

Genitourinary Cancer

Gynecologic Cancer

Head and Neck Cancer

Lung Cancer

Skin Cancer

Radiation Therapy

Genetic and Hereditary Screenings

Referring Practice Information