Patient Form - MercedCT

Name(Required)

First Middle Last

Date of Birth(Required)

Sex(Required)

Please select a gender

Male

Felmale

Are you a dependent?(Required)

Please select

Yes

Marital status(Required)

Please select

Married

Single

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Work #

Cell #(Required)

Driver's license #

SSN#(Required)

Primary language(Required)

Race(Required)

Religion(Required)

Pharmacy(Required)

Primary physician(Required)

Primary phone

Referring physician

Referring physician phone

Emergency contact(Required)

Phone(Required)

Relationship(Required)

Primary Insurance Information

Insurance Name(Required)

ID #(Required)

Subscriber First and Last Name(Required)

First Last

Secondary Insurance Information

Insurance Name

ID #

Subscriber First and Last Name

First Last

Initial(Required)

If there are any medical forms that need to be filled out by Merced Comprehensive Cancer Center staff there will be a charge of $20.00-$50.00 depending on the type of medical forms

Initial(Required)

There will be a $25.00 charge for all No Show and same day cancelation appointments: We require a 24 hour notice for all cancelation

Initial(Required)

I have received a copy of Comprehensive Cancer Center’s Notice of Privacy Practices

This feature is used as another source to contact patients and notify them of upcoming events. No medical information will be disclosed.

(I give Merced Cancer Center permission to email me at the above email address and I understand no medical history/information will be disclosed.)

May we speak with any family member regarding your care?

Yes

If you answered yes with whom may we speak regarding your care?

I hereby authorize Merced Comprehensive Cancer Center to furnish my insurance company with all information that they might request concerning my illness or injury. I hereby assign all Payments to Merced Comprehensive Cancer Center to which I am entitled and responsible Merced Comprehensive Cancer Center for all charges covered by this assignment. All charges not covered by this assignment and all charges not covered by the insurance company will be my responsibility.

Signature(Required)

Date(Required)

Please indicate if patient is in a nursing facility or rehabilitation facility

Name of Facility

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Admission

Contact Person

(All patients coming to be seen at our office will need prior Authorization prior to any visits from the Facility which the patient is staying in.)