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Louis J. Avvento, M.D. Alexander Zuhoski, M.D. Deepali Sharma, M.D. Sharon Sparacino, ANP-c, Cynthia Cichanowicz, ANP-c Melanie Acierno, DNP, Denise A. Albano, ANP-c 325 Meetinghouse Lane Southampton, NY 11968 Tel: (631) 204-9700 Fax: (631) 287-7277 1333 East Main Street

Riverhead, NY 11901 Tel: (631) 727-8500 Fax: (631) 208-9800

Patient Registration Forms

Name ______________________________________________ DOB _______________ Age _________

Birth Place City _____________________________ State __________ Country ____________________

Mailing Address _______________________________________________________________________

E-Mail Address _____________________________________________ SS# ____________________

Home # ________________________ Work # ____________________ Cell # _____________________

Emergency Contact __________________________________________ Relationship ________________

Home # ________________________ Work # ____________________ Cell # ______________________

Primary Care Doctor _________________________________________ Phone # ____________________

Living Will: Yes No (if yes, name: ____________________________________________) DNR: Yes No

Durable Power of Attorney: Yes No (if yes, name: _____________________________________________)

Ethnicity: Are you Hispanic/Latino? Yes No

Race (circle ALL that apply): American Indian Asian White Black/African American Other

Marital Status: Single Married Divorced Domestic Partner Widowed

Current / Past Occupation: ________________________________________________________________

Medical Insurance Information

Primary Insurance ______________________________________ ID # ____________________________

Secondary Insurance ____________________________________ ID # ____________________________

Name of insured if other than patient ______________________________ DOB _____________________

Drug Prescription Information

Plan Name ___________________________ ID# ___________________ PCN# ____________________

BIN# ______________________ Tel no. __________________________

Mail Order Pharmacy: ________________________________ Tel no. ___________________________ __

Local Retail Pharmacy: ______________________________ Tel no. _____________________________

Authorization:

I hereby give authorization for Eastern LI Hematology/Oncology to furnish information to insurance carriers concerning my illness/accident and irrevocably assign to the doctor all payments for medical services rendered. I understand that I am financially responsible for all charges whether or not they are covered by my insurance.

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PATIENT ACKNOWLEDGEMENTS

PLEASE READ AND INITIAL EACH SECTION

APPOINTMENT CHECK IN

To ensure that Eastern LI Hematology Oncology has accurate up-to-date information please understand that our receptionists will ask you at EVERY appointment to provide the name of your insurance, pharmacy, primary care physician and any other pertinent information as deemed necessary. In order to update/confirm your current

medications, you will be asked to bring your medication bottles to every appointment. You may be also be asked to complete forms that have previously have been completed.

PT INITIALS _______________

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA)

I have read and understand the Privacy Notice outlining Eastern LI Hematology/Oncology’s responsibilities and my rights under HIPAA. A copy of this notice is online at available at www.ELIHO.com or provided upon request from the patient.

PT INITIALS _______________

INSURANCE (existing/changing) and REFERRALS

It is up to you to know your insurance coverage. For questions regarding your coverage/responsibilities, you should contact a customer service representative. The number can usually be found on the back of your insurance card. You should know what laboratory, radiology, home care agency and referral requirements that are set by your insurance company. This office will not take responsibility for obtaining that information. We REQUIRE a minimum of 2 business day’s notification when you are changing insurances. Please contact our billing department with your new insurance information. If we are not properly notified, referrals and/or pre-certifications may not be requested/received and charges accrued will be the patient’s financial responsibility.

PT INITIALS _______________

INSURANCE CO-PAYMENTS/COINSURANCES/DEDUCTIBLES

Co-payments are to be collected upon checking in with our front desk staff. No exceptions will be made unless arrangements have been made prior with our billing department and/or managers. Insurances that apply coinsurances/deductibles will require a credit card authorization on file unless arrangements are made prior to appointment with the Practice Administrator, Lynn Kay Winters.

PT INITIALS _______________

DRUG CO-PAYMENT ASSISTANCE PROGRAMS

Our office may investigate manufacturer’s co-pay assistance programs for some medication(s) commonly prescribed at Eastern LI Hematology/Oncology. You hereby authorize Eastern LI Hematology Oncology to apply on your behalf.

PT INITIALS ______________

MISSED APPOINTMENTS

Appointments that are missed for any reason aside from medical emergencies wit hout 2 business day’s notice are subject to a 25$ MISSED APPOINTMENT CHARGE. Any such charges are due and payable upon receipt of notice.

PT INITIALS ______________

I acknowledge that I have read and understand all of the above.

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AUTHORIZATION FOR MEDICAL INFORMATION TO BE GIVEN

WHO MAY WE GIVE INFORMATION TO IN REGARDS TO YOUR CASE?

We take patient confidentiality very seriously. In order to ensure that our staff does not

give out information to individual(s) that you have not approved, we ask that you fill out the

section below. Only these individuals will be apprised of your case history and progress.

Name/Relationship

Primary Contact #

Secondary Contact #

 PLEASE CHECK AND INITIAL IF YOU DO NOT WISH ANYONE TO HAVE

INFORMATION IN REGARD TO YOUR MEDICAL CONDITION. THIS CAN ONLY

BE CHANGED IN WRITING BY YOU. PT INITIALS ________________

TO ENSURE CONTINUITY OF CARE, PLEASE SEND ALL PROGRESS NOTES, TEST

RESULTS TO:

Doctor Name

Address

Phone

Fax

PATIENT SIGNATURE ________________________________________ DATE _________

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MEDICATION / ALLERGY LIST (attach additional sheets if necessary)

Name ______________________________ Pharmacy _________________________________

MEDICATIONS

Name of Medication

(attach additional sheets if necessary)

Dose

Frequency

DRUG ALLERGIES

Name of Drug

(attach additional sheets if necessary)

Reaction

Height:

Weight:

SMOKING

STATUS:

 NEVER

SMOKED

FORMER

SMOKER, QUIT

# ____ YEARS

AGO

CURRENT

EVERYDAY

SMOKER

CURRENT

“SOME

DAYS”

SMOKER

ALCOHOL USE:

FREQUENT OCCASIONAL NEVER

CURRENT IV

DRUG USE:

FREQUENT OCCASIONAL NEVER

PAST IV DRUG

USE:

FREQUENT OCCASIONAL NEVER

TRANSFUSION

HISTORY

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MEDICAL HISTORY

TEST

DATE OF TEST

NAME OF FACILITY

MAMMOGRAM

PAP/GYN

EXAM

COLONOSCOPY

ENDOSCOPY

PSA

CHEST XRAY

PET SCAN

MRI

CT SCAN

BLOODWORK

OTHER PERTINENT MEDICAL HISTORY:

TYPE

DATE

SURGICAL HISTORY:

TYPE

DATE

ADDITIONAL INFORMATION YOU WOULD LIKE YOUR PHYSICIAN TO KNOW:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

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FAMILY CANCER HISTORY FORM

Please provide as much information as possible. You may not know all of the information or

specific dates. Any area that you are unsure about, please mark with a question mark (?) next to

it. If more space is needed, please attach a separate sheet of paper.

Family members with cancer diagnoses

Relationship to you (i.e.:

mother, son, niece, etc)

Current Age

(indicate if

deceased)

Type of cancer

Age when

diagnosed with

cancer

References

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