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Patient form

Westridge Shopping Center


PATIENT REGISTRATION

PLEASE PRINT AND COMPLETE ALL ENTRIES


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REGISTER EMAIL FOR CARESPACE, HAWAII CANCER CARE’S PATIENT PORTAL


INSURED/RESPONSIBLE PARTY INFORMATION


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INSURANCE INFORMATION

PRIMARY DOCTOR/FAMILY DOCTOR
REFFERING DOCTOR
IN CASE OF EMERGENCY CONTACT (PLEASE INCLUDE AT LEAST 2 CONTACTS)
RELATIONSHIP
PHONE NUMBER

ASSIGNMENT AND RELEASE : I hereby authorize my insurance benefits be paid directly to the physician and I am financially responsible for non-covered services. I also authorize the physician to release any information required in the processing of this claim and all future claims. If my account is sent to a collection agency, I agree to pay all collection and attorney fees.


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RELEASE OF INFORMATION
I understand that:
● once “this facility” discloses my health information by my request, it cannot guarantee that Recipient will not re-disclose my health information to a third
party. The third party may not be required to abide by this Authorization or applicable federal and state laws governing the use and disclosure of my health information.
● I may make a request in writing at any time to inspect and/or obtain a copy of my health information maintained at this facility as provided in the Federal
Privacy Rule 45 CFR (164.524).
● my records are protected and cannot be disclosed without written permission
● this Authorization will remain in effect for one year or I provide a written notice of revocation to the Medical Record Department.


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Financial Agreement & Responsibility

The services that will be provided to you will be paid (check one of the following):
SELF-PAY PLAN
Definition: Under this payment method, charges for services are paid in full prior to the day of the treatment.
INSURANCE PLAN
Definition: Charges will be billed to your insurance company. Deductible and Co-payment if applicable is due on the day of your treatment.
1. I understand that it is my responsibility to provide Hawaii Cancer Care with a copy of my current insurance card and to obtain a referral from my Primary Care Physician (if required by my insurance). Hawaii Cancer Care is not obligated to see patients without a valid referral. If I do not have insurance or my insurance does not cover my treatment, I will be considered Self- Pay patient and be financially responsible for the total amount of the services provided. I will notify Hawaii Cancer Care upon any change in my insurance.
a.I further understand that in consideration of the services provided, I am directly and primarily responsible to pay the amount of all charges incurred for services and procedures rendered at Hawaii Cancer Care which are not covered or reimbursed by my insurance. I am responsible for any applicable deductible or co-payments prior to the provision of services. Hawaii Cancer Care will provide me with an estimate of my total financial responsibility and the date by which this amount must be paid in full. I understand that due to the individual needs of each treatment, or procedure, this fee is only an estimate. In the event my care exceeds the amount of the estimate, I will be financially responsible for the balance.
2. My right to payment for all pharmaceuticals, procedures, tests, medical equipment rentals, supplies and nursing/physician services including major medical benefits is hereby assigned to Hawaii Cancer Care This assignment covers any and all benefits under Medicare, other government sponsored programs, private insurance and any other health plans. I acknowledge this document as a legally binding assignment to collect my benefits as payment of claims for services.
THIS AGREEMENT WILL REMAIN IN EFFECT UNLESS REVOKED BY ME IN WRITING.
I have read and accept the terms and conditions of the Financial Agreement & Responsibility.


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I have read and received a copy of the above statements and accept the terms. A duplicate of the statement is considered the same as original.

,direct my health care and medical services providers and payers to disclose and release my protected health
information described below to:

Health Information to be disclosed upon the request of the person named above – (Check either A or B):
Health Information


Mental health records




Form of Disclosure (unless another format is mutually agreed upon between my provider and designee):
Form of Disclosure



This authorization shall remain in effect from the date signed below until (please check one):
expiration



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Note: HIPAA Authority for Right of Access: 45 C.F.R. § 164.524
Resource provided by the ABA Commission on Law and Aging I www.americanbar.org/aging

HAWAII CANCER CARE

PROVIDER REQUEST FOR HEALTH INFORMATION

INSTRUCTIONS: PLEASE FILL IN ALL RELEVANT ITEMS ASTERISKED (*)


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*Purpose of Request:

Treatment(Required)


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Payment/Billing

*Specific Information Requested:
Billing(Required)




Billing




Billing



Other (please specify)

(initial) I agree to the release of the following information should it be contained in my medical record:
Acquired Immune Deficiency Syndrome (AIDS) of HIV, Alcohol and/or drug abuse treatment, or behavioral or mental health services. (If I do not specifically agree, this information will not be disclosed):
*Unless otherwise revoked, this authorization will expire on the following date or event:

If a date or event is not specified, this authorization will expire two (2) years from my date of signature below.
I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the requesting physician. I understand that the revocation will not apply to information that has already been disclosed in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.
I understand that authorizing disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not to sign this form in order to assure treatment. I understand that I may inspect or copy the information to
be used or disclosed, as provided in 45 CFR 164.524. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclose and the information may not be protected by federal confidentiality rules. I hereby release the physicians of Hawaii Cancer Care, INC., its employees and its agents from all liability and all claims of any nature pertaining to the disclosure of information described above.


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Hereditary Cancer Risk Assessment

Most of the time, cancer happens by chance. However, in some families cancer may be caused by change in certain genes that can be passed from generation to generation. These genetic changes significantly increase a person’s risk for certain cancers, including a second cancer in those who have been diagnosed. Family members will benefit from this information, as will you, since hereditary cancer risk can be significantly reduced with the right medical interventions. A careful review of your family history is an essential first step, so please check all of the boxes that apply to you:

Have YOU been diagnosed with…

YES
NO
UNCERTAIN
Breast cancer before age 50?
Breast cancer before age 50?



Ovarian cancer at any age?
Ovarian cancer at any age?



Two breast cancers, or breast and ovarian cancer?
Two breast cancers, or breast and ovarian cancer?



Breast cancer at any age? (Male Gender)
Breast cancer at any age? (Male Gender)



Colon or uterine cancer before age 50?
Colon or uterine cancer before age 50?



Colon or uterine at any age with family history of either?
Colon or uterine at any age with family history of either?



Two colon cancers, or colon and uterine cancer?
Two colon cancers, or colon and uterine cancer?



20 or more cumulative colon polyps?
20 or more cumulative colon polyps?



Two or more melanomas?
Two or more melanomas?



Melanoma and pancreatic cancer?
Melanoma and pancreatic cancer?



Are you of Ashkenazi Jewish Ancestry?
Are you of Ashkenazi Jewish Ancestry?



Have any of your FAMILY members been diagnosed with…

WHO?

(Please indicate maternal or paternal as they are BOTH important)
Breast cancer before age 50?
Breast cancer before age 50?


Ovarian cancer at any age?
Ovarian cancer at any age?


Two breast cancers, or breast and ovarian cancer?
Two breast cancers, or breast and ovarian cancer?*


Breast cancer at any age? (Male Gender)
Breast cancer at any age? (Male Gender)


Colon or uterine cancer before age 50?
Colon or uterine cancer before age 50?


Two colon cancers, or colon and uterine cancer?
Two colon cancers, or colon and uterine cancer?


20 or more cumulative colon polyps?
20 or more cumulative colon polyps?


Two or more melanomas?
Two or more melanomas?


Melanoma and pancreatic cancer?
Melanoma and pancreatic cancer?


* Can be two cancers in one person, or two or more people in your family with these cancers
If any YES boxes are checked, you have a personal or family history suggestive of one of the more common hereditary cancer syndromes and are a candidate for further risk assessment and, if appropriate, genetic testing to determine if a gene change exists. We will discuss this with you and provide you with additional
information that will help you understand your individual risks and how to best address them.
Candidate for further risk assessment and/or genetic testing

Patient offered genetic testing

Information given to patient to review

Accept/Decline


Follow up appointment scheduled Date:


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Patient education DVD distributed to the patient

Patient education tool pamphlet distributed to the patient


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PATIENT HEALTH SURVEY


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I. CURRENT MEDICATIONS

Date Started
Drug Name
Dosage
Frequency

HERBAL OR COMPLEMENTARY MEDICATIONS

II. SOCIAL HISTORY

Select what best describes your ethnic background (You can check more than one)
Select what best describes












Select what best describes










What is your highest level of education? (Please choose only one response)
What is your highest level of education?








Current Job or Previous Occupation:










III. SMOKING, ALCOHOL & DRUG HISTORY

SMOKING, ALCOHOL & DRUG

If you have ever smoked, what did you smoke? choose all that applies.




If you have ever smoked, on average, how many packs per day did you smoke?
If you have ever smoked, on average, how many packs per day did you smoke?






ALCOHOL & DRUG HISTORY

Have you ever or do you currently drink alcohol?



If your alcohol intake in the past was different from now, how many alcoholic beverages did you consume weekly?





How many alcoholic beverages do you consume weekly? Please approximate the number of beverages per week:





Has anyone suggested you cut down the amount you drink?


Have you needed an “eye-opener” drink in the morning?


Do you feel guilty drinking?


Do you feel angry if someone suggests you stop drinking or cut back?


Have you ever had a DUI?


Have you had blackouts?


IV. PHYSICAL ACTIVITY

Do you have a regular exercise activity?


How active are you?





V. FAMILY HISTORY

If adopted

Do you have any family members with cancer? (Living or Deceased)

Cancer Type
How many relatives?
Relationship to you?
Age (years) at diagnosis?
Cancer Type

Cancer Type

Cancer Type

Cancer Type

Cancer Type

Cancer Type

Cancer Type

Cancer Type

Cancer Type

Cancer Type

Cancer Type

Cancer Type

Cancer Type

Cancer Type

Cancer Type

Cancer Type

Cancer Type

Cancer Type

Cancer Type

Cancer Type

Cancer Type

Are you interested in genetic counseling?


Do you have family members with other illnesses? (Living or Deceased)

Illness
How many relatives?
Relationship to you?
Illness

Illness

Illness

Illness

Illness

Illness

Illness

Illness

Illness

Illness

VI. PAST CANCER HISTORY

Have you ever had cancer in the past? (If not, then please skip this section)
Do you have cancer now?


Cancer Type
cancer type

cancer type

cancer type

cancer type

cancer type

cancer type

cancer type

cancer type

cancer type

cancer type

cancer type

cancer type

cancer type

cancer type

cancer type

cancer type

cancer type

cancer type

VII. SURGICAL HISTORY

Please indicate in the table below your history of surgical procedures (if none, then skip this section)
Type of surgery
Date of Surgery
Doctor
Type of surgery

Type of surgery

Type of surgery

Type of surgery

Type of surgery

Type of surgery

Type of surgery

Type of surgery

Type of surgery

Type of surgery

VIII. MEDICAL HISTORY

GENERAL SYMPTOMS

1) Have you had weight loss within the past six months?
Have you had weight loss within the past six months?


2) Do you have any difficulty sleeping?
Do you have any difficulty sleeping?


4) Have you felt fatigued (tired) within the past 3 months?
4) Have you felt fatigued (tired) within the past 3 months?


(pounds)

EYE DISORDERS

5) Do you wear eyeglasses?
5) Do you wear eyeglasses?


6) Do you have trouble seeing or eye disorders ?
6) Do you have trouble seeing or eye disorders ?


(for example blindness, bleeding, cataracts, glaucoma or detached retina?)

EAR, NOSE & THROAT

7) Do you have difficulty hearing?
7) Do you have difficulty hearing?


8) Do you have a history of sinus problems?
8) Do you have a history of sinus problems?


9) Do you have a history of voice changes?
9) Do you have a history of voice changes?


CARDIOVASCULAR

10) Have you ever had a heart attack?
10) Have you ever had a heart attack?


11) Have you ever had chest pain (angina)?
11) Have you ever had chest pain (angina)?


12) Do you have high blood pressure?
12) Do you have high blood pressure?


13) Have you ever been treated for heart failure?
13) Have you ever been treated for heart failure?


14) Do you have a history of heart arrhythmias (irregular or too fast)
14) Do you have a history of heart arrhythmias (irregular or too fast)


15) Do you have poor blood circulation in your legs?
15) Do you have poor blood circulation in your legs?


16) Do you have swelling of your arm or legs?
16) Do you have swelling of your arm or legs?


17) Do you have high cholesterol or triglycerides in your blood?
17) Do you have high cholesterol or triglycerides in your blood?


RESPIRATORY

18) Do you have coughing or shortness of breath (dyspnea)?
18) Do you have coughing or shortness of breath (dyspnea)?


19) Do you have asthma, emphysema, bronchitis, or lung disease?
19) Do you have asthma, emphysema, bronchitis, or lung disease?


20) Have you ever had tuberculosis (TB)or a positive skin test (PPD)?
20) Have you ever had tuberculosis (TB)or a positive skin test (PPD)?


21) If Yes, did you take medications?
21) If Yes, did you take medications?


GASTROINTESTINAL

22) Have you had any nausea or vomiting recently?
22) Have you had any nausea or vomiting recently?


23) Do you have difficulty swallowing or eating?
23) Do you have difficulty swallowing or eating?


24) Do you have recent changes in your bowel habits?
(diarrhea or constipation)
24) Do you have recent changes in your bowel habits?


25) Do you have blood in your stool?
25) Do you have blood in your stool?


26) Do you have cirrhosis or serious liver damage?
26) Do you have cirrhosis or serious liver damage?


27) Do you have a history of hepatitis?
27) Do you have a history of hepatitis?


28) Do you have stomach ulcers or peptic ulcer disease?
28) Do you have stomach ulcers or peptic ulcer disease?


29) Have you had a problem with reflux?
29) Have you had a problem with reflux?


MUSCULOSKELETAL

30) Do you have pain in your joints, arms, legs, or muscles?
30) Do you have pain in your joints, arms, legs, or muscles?


31) Do you have arthritis?
31) Do you have arthritis?


32) Has the condition been call “rheumatoid”
32) Has the condition been call “rheumatoid”


33) If yes, do you take medications for it regularly?
33) If yes, do you take medications for it regularly?


34) Do you have lupus or polymyalgia rheumatica?
34) Do you have lupus or polymyalgia rheumatica?


35) Have you ever had chronic fatigue syndrome?
35) Have you ever had chronic fatigue syndrome?


36) Have you ever had gout?
36) Have you ever had gout?


37) Have you ever had broken bones or compression fractures?
37) Have you ever had broken bones or compression fractures?


GENITOURINARY

38) Have you ever had problems with your kidneys?
38) Have you ever had problems with your kidneys?


39) Have you ever had blood in the urine?
39) Have you ever had blood in the urine?


40) Have you ever had urinary tract or bladder infections?
40) Have you ever had urinary tract or bladder infections?


41) Do you have urinary incontinence?
41) Do you have urinary incontinence?


42) For females only. Any vaginal bleeding or abnormal discharge?
42) For females only. Any vaginal bleeding or abnormal discharge?


43) For females only. Have you used oral contraceptives in the past?
43) For females only. Have you used oral contraceptives in the past?


44) For females only. Have you used hormonal replacement drugs?
44) For females only. Have you used hormonal replacement drugs?


SKIN PROBLEMS

47) Do you have skin problems or any rashes?
47) Do you have skin problems or any rashes?


48) Do you have non-healing skin wounds?
48) Do you have non-healing skin wounds?


49) Have you ever had skin cancer?
49) Have you ever had skin cancer?


NEUROLOGICAL / PSYCHOLOGICAL

50) Have you had a blood clot or bleeding in the brain?
50) Have you had a blood clot or bleeding in the brain?


51) Do you have difficulty moving an arm or leg?
51) Do you have difficulty moving an arm or leg?


52) Have you ever lost sensation in an arm or leg?
52) Have you ever lost sensation in an arm or leg?


53) Have you ever had a seizure or epilepsy?
53) Have you ever had a seizure or epilepsy?


54) Do you have a history of mental health problems?
54) Do you have a history of mental health problems?


55) Do you have a history of anxiety or depression?
55) Do you have a history of anxiety or depression?


56) Have you taken or taking medications for any mental illness?
56) Have you taken or taking medications for any mental illness?


57) Are you under the care of a mental health professional?
57) Are you under the care of a mental health professional?


58) Do you have Alzheimer’s Disease, or any form of dementia?
58) Do you have Alzheimer’s Disease, or any form of dementia?


ENDOCRINE

59) Do you have diabetes or high blood sugar?
59) Do you have diabetes or high blood sugar?


60) If yes, is it treated by modifying your diet?
60) If yes, is it treated by modifying your diet?


61) By medications taken by mouth?
61) By medications taken by mouth?


62) By insulin injections?
62) By insulin injections?


63) Has your diabetes caused problems with your kidneys or eyes?
63) Has your diabetes caused problems with your kidneys or eyes?


64) Do you have a history of thyroid disease?
64) Do you have a history of thyroid disease?


65) If Yes, then did you take medications to treat it?
65) If Yes, then did you take medications to treat it?


HEMATOLOGIC/LYMPHATIC DISORDERS

66) Do you have leukemia or polycythemia vera or lymphoma?
66) Do you have leukemia or polycythemia vera or lymphoma?


67) Have you ever had bleeding that would not stop?
67) Have you ever had bleeding that would not stop?


68) Do you have hemophilia or von Willebrand’s disease?
68) Do you have hemophilia or von Willebrand’s disease?


69) Have you ever received any blood transfusions?
69) Have you ever received any blood transfusions?


PATIENT EDUCATION

70) Would you like more information about your disease?
70) Would you like more information about your disease?


71) Are you interested in new therapy or a clinical trial?
71) Are you interested in new therapy or a clinical trial?


72) Do you have an advance directive or living will?
72) Do you have an advance directive or living will?


SCREENING:

PHYSICIAN REVIEW:


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Principal Care Management Enrollment Form


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Principal Care Management (PCM) is supported by CMS Medicare/Medicaid to benefit millions of patients that have one chronic disease. The benefits of the PCM program address the patient’s condition as quickly as possible without delay in care. In addition, to your oncologist/hematology, a team of Hawaii Cancer Care (HCC) staff will help manage your care to ensure you are receiving quality care throughout your cancer journey.
Medicare, private and commercial insurances will now allow providers and other licensed healthcare providers to be reimbursed for services through the PCM program. Your oncologist/hematologist and nurse practitioner will supervise all care provided by HCC healthcare staff, such as nurses, social workers, pharmacists, and medical assistants. These services include monthly calls to check on your progress as you are on treatment, the management of symptoms related to your prescribed treatment, medication management/administration, and other services related to your plan of care.
Hawaii Cancer Care team will develop a comprehensive care plan tailored to your treatment prescribed by your physician. This will address any questions or concerns you may have regarding your treatment, such as your medications, scheduling of follow-up appointments, managing symptoms that may occur and to provide resource information to assist you during the course of your treatment.
By enrolling in the PCM program, HCC will bill your primary insurance as well as your secondary insurance, every 30 days for the PCM services provided to you for a period of one year. There may be a nominal copayment or co-sharing charged to you by your insurance. We will keep accurate and complete records of the time spent with you, should you ever have any questions about the PCM services provided by Hawaii Cancer Care.
You have the right to remove your enrollment from the PCM program at any time. However, Hawaii Cancer Care will continue to manage your care related to your cancer diagnosis and treatment. Our goal is to provide the best quality care for you, to keep you out of the hospital, to minimize costs and inconvenience to you, due to unnecessary visits to doctors, emergency rooms, labs, or hospitals. We know your time and health is valuable and we hope that you will consider participating in the PCM program with Hawaii Cancer Care.

Agree or Not agree


to participate in the Principal Care Management
Program (PCM) at Hawaii Cancer Care.


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