SITESEARCH
home | sitemap | contact us
Call : (718) 732-4000  Fax : (718) 881-3035  Email : info@eastchestercenter.com
 

Please complete the following form to register online.  We will respond to your application shortly. (*Required)
 
 
First Name* :
Last Name* :
SS#* : - -
Date of Birth * : Month   Day   Year   
Marital Status* :  Single  Married  Widowed  Separated  Divorced 
Address* :
Addres Line #2 :
City* :
State* :
Zip* :
Home Phone or Primary Phone Number* :
Cell Phone :
Work Phone :
Your Email Address :
 
Reffered by* :
Address :
Addres Line #2 :
City :
State :
Zip :
 
Spouse's Name :
SPOUSE'S EMPLOYER NAME/ADDRESS
Name :
Address :
Addres Line #2 :
City :
State :
Zip :
 
Emergency Contact:
Tel# :
Relationship :
 
PATIENT EMPLOYER INFORMATION
Employer Name :
Tel# :
Employer Street Address :
City :
State :
Zip :
Patient Occupation :
 
INSURED PERSON (IF NOT PATIENT)
First Name :
Last Name :
Employer Name :
Tel# :
Employer Street Address :
Addres Line #2 :
City :
State :
Zip :
   
Insured's Relationship to Patient :
Insured's Date of Birth : Month   Day   Year   
 
INSURANCE
Primary Insurance Co. Name* :
ID#* :
Group# :
Phone# :
   
Secondary Insurance Co. Name :
ID# :
Group# :
Phone# :
 
AUTHORIZATION TO RELEASE INFORMATION AND ASSIGNMENT OF BENEFIT
I request that payment of authorized benefits be made to Eastchester Center for Cancer Care on my behalf for any services furnished to me by Eastchester Center for Cancer Care, including physician services. I authorize any holder of medical or other information about me to release to the Health Care Financing Administration or my other insurance companies and their agents any information needed to determine these benefits or other benefits for related services.

I certify that the information I have reported with regard to my insurance coverage is correct.

I permit a copy of this authorization to be used in place of the original.  This authorization may be revoked by me at any time in writing.
   
DATE : 08.28.2008
SIGNATURE
  (Please type your full name here)
How did you hear about us? :
 
PATIENT CONSULTATION INFORMATION SHEET
REFERRING PHYSICIAN INFORMATION (IF DIFFERENT FROM ABOVE)
Name* :
Address :
Addres Line #2 :
City :
State :
Zip :
Phone :
   
Diagnosis :
Prior Treatment :
Surgeries and Hospital Where Performed :
 
PRIMARY CARE PHYSICIAN INFORMATION
Name :
Address :
Addres Line #2 :
City :
State :
Zip :
Phone :
 
SURGEON INFORMATION (IF NOT REFERRING PHYSICIAN, ABOVE)
Name :
Address :
Addres Line #2 :
City :
State :
Zip :
Phone :
   
Radiology Test :
Pathology :
Blood Work :
 
INSURANCE INFORMATION   (OFFICE USE ONLY)
REFERRAL INFORMATION, FIRST VISIT :
CO-PAY REQUIRED/AMOUNT? $
DRUG PLAN?
INSURANCE VERIFIED :
EFFECTIVE DATE : Month   Day   Year   
 
PRIVACY PRACTICES ACKNOWLEDGEMENT
I have received the Notice of Privacy Practices, and I have been provided an opportunity to review it.
Privacy Notice*  
Name* : (Please type your full name here)
Date of Birth * : Month   Day   Year   
  Of patient, or if minor, parent or legal guardian
   
DATE : 08.28.2008


Home   |   About Us   |   Our Services   |   Clinical Trials   |   Education   |   Your Visit   |   News   |   Events   |   Sitemap   |   Contact Us
Privacy Policy    |   Disclaimer © 2006 EASTCHESTER CENTER FOR CANCER CARE