FORM I : REGISTRATION and AUTHORIZATION

FORM I : REGISTRATION and AUTHORIZATION
THIS AUTHORIZATION APPLIES TO ALL MEDICAL RECORDS, MATERIALS
AND INFORMATION PROVIDED TO THE SECOND OPINION
I am requesting a Second Opinion concerning my cancer diagnosis and
treatment. By signing this document I am authorizing thesecondopinion to
access my medical information and share it with physicians/medical specialists
associated with thesecondopinion service for the purpose of providing a medical
consultation to me and my treating physicians.
I understand that my records will be seen by employees of thesecondopinion,
who will distribute them only to the physicians and medical specialists involved in
providing my second opinion. All of my information will remain confidential. This
authorization also applies to any updated information that I may bring to my
second opinion meeting on my panel date.
I also give permission to provide a follow-up second opinion letter to myself and
my treating physicians, whom I shall designate at the time of the panel session.
I understand that thesecondopinion charges no fees for its services but accepts
tax deductible contributions as a non-profit organization.
I understand that I may revoke this authorization in writing at any time.
This authorization expires one year from the date shown below or upon my
revocation, whichever occurs earliest.
Patient Signature: _____________________________
Date:
Address: ______________________________
______________________________
______________________________
Phone: _______________________________
1200 Gough Street, Suite 500
San Francisco, CA 94109 415.775.9956 ph
www.thesecondopinion.org
415.346.8652 fx
Medical Intake Form--Form II
Name:
Date of Birth:
Email:
Phone:
Gender:
Home
Mobile
Address:
County:
Contact person, if other than patient:
Contact person's phone and or email :
Type of Cancer:
When were you diagnosed with cancer?
Have you received a prior Second Opinion?
Are you planning to Obtain Additional Opinions?
I will need the help of translator services.
If so where and when?
If so where and when?
Which Language?
How did you hear about us?
Why are you seeking a second opinion?
Please tell us briefly about your cancer diagnosis and treatment to date. This will help us determine
the records that will be needed for your panel review:
FORM III
PATIENT HEALTH INFORMATION RELEASE FORM
I HEREBY AUTHORIZE:
NAME OF HOSPITAL, DOCTOR, LABORATORY OR DEPARTMENT
ADDRESS
CITY
STATE
ZIP CODE
TO RELEASE TO: Howard B. Kleckner, MD
Medical Director
The Second Opinion
1200 Gough Street – Suite 500
San Francisco, CA 94109
RECORDS AND INFORMATION OF:
PATIENT NAME
ADDRESS
MEDICAL NUMBER
DATE OF BIRTH
TELEPHONE NUMBER
INTENDED USE:
SECOND OPINION CANCER CONSULTATIVE PANEL
Duration: I understand that this authorization is effective immediately and shall be valid for one year.
Right to Revoke: I understand that I may revoke this authorization in writing at any time.
Reuse: I understand that no other use will be made of this information without prior authorization from
me unless such use is specifically required/permitted by law.
RECORDS TO BE RELEASED:
MEDICAL RECORDS RELATED TO CANCER DIAGNOSIS, INCLUDING LAB
REPORTS, CONSULTATIONS, OPERATIVE REPORTS AND PATIENT SUMMARIES.
IMAGING STUDIES, X-RAYS AND REPORTS, CT scans, MRIs and REPORTS
MAMMOGRAMS, ULTRASOUNDS and REPORTS
PATHOLOGY SLIDES AND REPORTS
NUCLEAR SCANS AND REPORTS
Patient signature:
Date:
FORM IV: PHYSICIANS and MED INFO
Date:
Phone:
Name:
Home
Email:
Type of Cancer:
Have you received a prior Second Opinion?
If so where and when?
Are you planning to Obtain Additional Opinions?
I will need the help of translator services.
Mobile
If so where and when?
Which Language?
To the best of your knowledge, please list all physicians and medical facilities involved in your care.
Addresses and phone numbers are appreciated.
Oncologist:
, MD
Facility/Hospital:
Address:
Phone/Fax:
Dates under care:
Surgeon:
, MD
Facility/Hospital:
Address:
Phone/Fax:
Dates under care:
Radiation Oncologist:
Facility/Hospital:
Address:
, MD
Phone/Fax:
Dates under care:
Other Specialist:
Facility/Hospital:
Address:
Phone/Fax:
Dates under care:
Hospital/Facility:
Medical Records Department:
Address:
Radiology Department:
Address:
Pathology Department:
Address:
Other Department:
Address:
, MD
FORM V: STATISTICAL QUESTIONNAIRE
Name: (initials) ____________
Age: _________
Date: ___________
Gender: ____________
Type of Cancer:
How did you hear about our service?
The information below is used only to provide statistics to potential funding organizations.
No names will be used.
Ethnic identity: With which ethnic group/s do you identify? (e.g. African American, Asian, etc.)
Are you: (Please check the appropriate box.)
Employed
Retired
Unemployed
Disability
Other
Are you: (Please check one box below.)
Single
Married
Widowed
Divorced
Your Annual Income: (Please check one box below)
$50,000 or Less
$51,000 -$79,000
$80,000-100,000
$101,000 or Above
Is your medical care covered by (Please check all boxes that apply):
Medical insurance: (e.g. Aetna, Kaiser, Healthy SF, Health Net,
etc.) Medical Insurance and Medicare
Medicare Only
Covered California/Affordable Care Act: Kaiser, Blue Shield, etc.
Medi-Cal
Uninsured
Other
While we do not bill your insurance for our free services, we would like to know if your
insurance or health plan covers the cost of a 2nd Opinion outside of your plan’s network?
(Please check the appropriate box below.)
Yes
Partial with Co-Pay
No
I don't know