Online Scheduling

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Global Scheduling

Tell us about yourself *

New patient

Referring practice

Reason for Appointment *

Cancer Diagnosis or Suspicion

Benign Blood Disorder

Breast Surgery

Genetic and High Risk Counseling

Radiation Therapy

Non-Oncology Infusion

Tell us more about your diagnosis *

Blood Cancer

Breast Cancer

Gastrointestinal Cancer

Genitourinary Cancer

Gynecologic Cancer

Head and Neck Cancer

Lung Cancer

Skin Cancer

Other

Other

Intent of the visit *

Onboard a patient with a new diagnosis

Receive a second opinion

Transfer care to NECS

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 Consent

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

Upload Any Records You Have

Drop a file here or click to upload Choose File

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

Submit Records

Upload Any Records You Have

Drop a file here or click to upload Choose File

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 *

Name

First Name

First Name

Last Name

Last Name

Date of Birth *

Birth Sex *

Male

Female

Email *

Address *

Address

Address

Address

City

City

State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

State/Province

Zip/Postal

Zip/Postal

Patient's Primary Language *

English

Arabic

Cambodian

Chinese

French

Portuguese

Russian

Somali

Spanish

Vietnamese

Other

Other

Patient's Race *

American Indian

Black or African American

Native Hawaiian or Pacific Islander

White / Caucasian

Asian

Prefer not to answer

Unknown

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

Primary Care Provider

Name *

Name

First Name

First Name

Last Name

Last Name

Practice Name *

Phone *

Fax *

Does patient have an oncologist? *

Yes

No

Oncologist's Information

Name *

Name

First Name

First Name

Last 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. *

Abnormal Breast Imaging

Atypia (abnormal cells)

Breast Infection

Breast Lump

Breast Pain

Biopsy was Recommended

Dense Breast Tissue

Family History

Nipple Discharge

Nipple Inversion

Short Interval Breast Imaging Assistance

Biopsy and Additional Work Up

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 *

Office Contact

First Name

First Name

Last 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 *

Chiara Battelli, MD

David Benton, MD

Patrick Boland, MD

Elizabeth Dennis, DO

Matthew Dugan, DO

Devon Evans, MD

Yoko Fukuda, MD

Brian Haney, DO

Can Ilyas, MD

Eleni Nackos, MD

Laura Salama, MD

Christian Thomas, MD

John Winters, MD

No Preference

Are any of these social determinants a concern? *

Food Insecurity

Transportation

Finances and Bills

Lodging

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