Please list individuals we are authorized to speak with regarding your care/account: (Include the last four digits of their social number or their mother's maiden name for verification purposes, Thank You.)

SPOUSE / PARENT / GUARDIAN / RESPONSIBLE PARTY:

INSURANCE INFORMATION (Primary)

INSURANCE INFORMATION (Secondary)

To the best of my knowledge, all of the above information is true and complete. I understand that I am responsible to pay for all services rendered to me, and that I am willing to make specific arrangements to pay whatever part is not covered by insurance on a timely basis.

(PLEASE REMEMBER THAT INSURANCE IS CONSIDERED A METHOD OF REIMBURSING THE PATIENT FOR FEES PAID TO THE DOCTOR, AND IS NOT A SUBSTITUTE FOR PAYMENT.) IN ORDER TO MONITOR YOUR COST OF BILLINGS, WE REQUEST THAT OUR CHARGES FOR OFFICE VISITS BE PAID AT THE CONCLUSION OF EACH VISIT.

Thank you

If this account is assigned to an attorney for collections and/or suit, the prevailing party shall be entitled to reasonable attorney's fees and costs of collection. I hereby assign all medical benefits to which I am entitled to my physician for services rendered to my dependent or me. This assignment will remain in effect until revoked, by me, in writing. A photocopy of this assignment is to be considered as valid as the original.

MEDICARE ASSIGNMENT/SIGNATURE ON FILE

I request that payment of authorized Medicare benefits be made either to me, or on my behalf to North Houston Cancer Clinic for any services furnished me by that physician/supplier. I authorize any holder of medical information about me to the Centers for Medicare and Medicaid Services, formerly the Health Care Administration, and its agents, any information needed to determine these benefits, or the benefits payable for related services.

MEDICAL & SURGICAL HISTORY

Surgery

Please list the names of Hospitals and Clinics where you have had MRI/CT/XRAYS

Preventive Health Maintenance

Medication and Allergy List

Please list all prescriptions, vitamins, herbs, and over-the-counter medications that you are currently taking and /or bring your medications with you to your appt.

Allergies

SOCIAL & FAMILY HISTORY

Do you use any of the following? (Please check all that apply)

Is there are any family history of Cancer/ Blood Disorders? Such as Colon cancer, Breast cancer, throat cancer, lung cancer, leukemia, lymphoma , age at diagnosis if known,