Online Scheduling

Second Opinions

Here, we are second-opinion friendly. Serious cases are often shared at tumor boards which include a group of physicians looking at your specific diagnosis. This may include physicians at Dana-Farber Cancer Institute. If you would like to have a second opinion by our NECS physicians, send us your information below and be sure to give us permission to pull your records for review.

Becoming a New Patient

We believe that patients can choose where they want to receive care. Because of this, we were one of the first oncology practices to not require a physician referral to be seen. Our teams will work with your current physician and with your insurance to make sure you have everything you need to make great care decisions. To start the process, fill out the form below.

Referring a Patient

Referring practices should use the following form to start a patient referral. We will reach out for records and communicate next steps.

Most patients with a new cancer diagnosis can expect a confirmation call within two days and an initial visit with a physicians within 5 business days. Schedule an appointment below or if this is for a new patient, call us toll free at: 833-826-6327.

Unified Scheduling

Tell us about yourself. *

I'm a Patient with a New Diagnosis

I'm Requesting for a Patient

Referring Practice

Are you Authorized to Sign a Release of Health Information? *

Yes

I Don't Know

What is Your Relationship to the Patient? *

Family Member with Authorization of Legal Representation

Legal Guardian

Health Care Power of Attorney

Other Legal Representative

What is the Purpose of the Appointment? *

Consult for a Cancer Diagnosis

Consult for a Blood Disorder Diagnosis

Consult for a Second Opinion

Consult for Surgery

Set Up Non-Oncology Infusion Services

What is the Purpose of the Appointment? *

Become a Patient After a Cancer Diagnosis

Become a Patient After a Blood Disorder Diagnosis

Receive a Second Opinion

Discuss Needed Surgery

Transfer Care to New England Cancer Specialists

Receive Non-Oncology Infusion Services

Patient's First and Last Name *

Patient's First and Last Name

First

Last

Patient Date of Birth MM/DD/YYYY *

Birth Sex *

Male

Female

Patient Email

Patient Phone *

Patient Address *

Patient Address

City

State/Province

Zip/Postal

Patient's Primary Language Spoken *

English

Arabic

Cambodian

Chinese

French

Portuguese

Russian

Somali

Spanish

Vietnamese

Other

Patient's Race *

American Indian

Black or African American

Native Hawaiian or Pacific Islander

White / Caucasian

Asian

Prefer not to answer

Don't know

Patient's Ethnicity *

Latino or Hispanic

Not Latino or Hispanic

Prefer not to answer

Select all that apply *

Patient is in a skilled nursing facility

Patient is ambulatory

Neither

Does Patient Have an Oncologist? *

Yes

Patient's Oncologist's Name *

Patient's Hospital or Oncology Practice *

Oncologist's Phone *

Oncologist's Fax

What is the Patient's Diagnosis or Reason for This Request? *

Diagnosis Classification *

Non-Cancerous Blood Condition

Breast Cancer

Gastrointestinal (Anal, Biliary Tract, Colorectal, Esophageal, Gastric, Gastroesophageal, etc...)

Genitourinary (Penile, Prostate, Renal, Testicular, Urothelial, etc...)

Gynecologic (Cervical, Ovarian, Uterine/Endometrial, Vulva, ect...)

Head and Neck

High-Risk Genetics (DCIS, Family History, etc...)

Lung

Blood Cancer (Leukemia, Lymphoma, Myeloma, Amyloidosis, Myelodysplastic Syndrome, Waldenstroms Macrogloulinemia, etc...)

Skin (Carcinoma, Melanoma, etc...)

OtherOther

If you have a cancer diagnosis, let us know the location of the original tumor.

Referring Office Contact Name *

Referring Office Name *

Referring Office Phone *

Referring Office Fax *

Referring Office Email *

Referring Office NPI#

Referring Practice Tax ID#

Upload Records

Maximum file size: 134.22MB

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.

Are you UNABLE to provide any of the following *

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

Does Patient Have a Primary Care Provider? *

Yes

Unknown

Patient's Primary Care Provider's Name *

Which Primary Care Practice or Hospital is the Patient's Physician With? *

Primary Care Provider's Phone *

Primary Care Provider's Fax *

Does Patient Consent For Us To Request Their Medical Records? *

Yes

Unsure

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.

I grant permission to share my information From: *

To: *

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)

None

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.

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

Legal Representative Signature *

Clear

Does Patient Have Insurance *

Yes

Insurance Carriers

Insurance Carrier *

Policy Number *

Phone *

Add Remove

Which Medications are being Requested for Infusion? *

Which would you rather choose, your physician or where you receive care?

Physician

Location

Do You Have a Provider Preference? *

Dr. Chiara Battelli

Dr. David Benton

Dr. Patrick Boland

Dr. Elizabeth Dennis

Dr. Matthew Dugan

Dr. Devon Evans

Dr. Yoko Fukuda

Dr. Brian Haney

Dr. Can Ilyas

Dr. Eleni Nackos

Dr. Laura Salama

Dr. Jillian Smith

Dr. Paige Teller

Dr. Christian Thomas

Dr. John Winters

No Preference

Do You Have a Location Preference? *

Portsmouth, NH

Kennebunk, ME

Westbrook (Rock Row), ME

Topsham, ME

No Preference

Your Name *

Your Name

First

Last

Your Phone *

Your Email *

Any Additional Information that You Wish to Provide *

Our Financial Advocates may be able to help patients find help with various needs during treatment. Are any of these a concern? *

Food

Transportation

Bills and other Finances

Lodging

Other

None

Captcha

If you are human, leave this field blank.

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Clinical Trials

New England Cancer Specialists works hard to stay at the forefront of cancer research and clinical trials. New clinical trials are always being added so reach out to see if a trial you are looking for may be available soon.

Online Scheduling Locations

Patient Financial Advocacy

Patient Advocates

If you are experiencing financial distress due to treatment costs or the inability to work, we want you to know that we offer financial advocates who are here to help. Our advocates can assist you in finding resources and support through various third-party organizations, ensuring you have access to the financial assistance you need during this challenging time. Please don’t hesitate to reach out to our team for guidance and support.

Learn more

Online Scheduling

Second Opinions

Becoming a New Patient

Referring a Patient

Insurance Carriers

Clinical Trials

Online Scheduling Locations

Portsmouth Campus

Kennebunk Campus

Topsham Campus

Rock Row Campus

Patient Financial Advocacy

Patient Advocates