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

No

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

First

Last

Patient Date of Birth MM/DD/YYYY

Birth Sex

Male

Female

Patient Email

Patient Phone

Patient Address

City

State/Province

Zip/Postal

Patient's Primary Language Spoken

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

No

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?

Referring Office Contact Name

Referring Office Name

Referring Office Phone

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

No

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

No

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 authorize the release of information between the following dates.

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

No

Insurance Carriers

Insurance Carrier

Policy Number

Phone

Add Remove

Which Medications are being Requested for Infusion?

Do You Have a Provider Preference?

Do You Have a Location Preference?

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?

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Online Scheduling

Insurance Carriers