In keeping with the mission of Integrated Community Oncology Network, it is our foremost concern to provide for our patients’ healthcare needs. We want our patients to be able to make complete and informed decisions regarding their care and treatment so that we have the best opportunity to serve their needs. Adopted in 1998 by the U.S. Advisory Commission on Consumer Protection and Quality in the Health Care Industry, this document outlines the rights and responsibilities of patients. We support and protect the fundamental rights of each patient according to the adopted guidelines.

Knowing your personal medical history is important. Our North Florida Hematology and Oncology office suggests that you fill out this form prior to your appointment, so that you have time to compile and verify information on your personal medical history. At our other practices, your medical history will be obtained through a verbal interview. You may wish to use this form as a reminder of questions that may be asked at your first appointment.

Medications can be rather confusing; this is a blank form for you to print out from your computer. You can fill in the blanks with the medications you take on a regular basis. It will help you to remember what you are taking, when to take it and why you are taking the medication. Keep a few extra blank copies on hand so that if your medication regime changes, you can make a new list.

1.) Receipt of Privacy Notice 2.) Exception to the Release 3.) Request to Restrict This notice verifies that you have been provided with a copy of our Notice of Privacy Practices. To ensure that our records are accurate and complete, this form must be signed and returned to our office staff for your records. Additionally, this form provides space for you to indicate any exceptions to disclosure of your Protected Health Information (“P.H.I.”) as well as any restrictions to your P.H.I.

If time permits, you will receive this form in the mail from your physician’s office. If you have not received one, please feel free to read our online copy and/or print one from this web site. You will be asked to complete this form for your records.

This is a copy of the form you will be required to complete regarding your insurance information and liability.

Effective April 14, 2003, new privacy laws were established called the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). This important summary information is for your review. At your physician’s office, you will be asked to sign a form acknowledging that you have received this Notice of Privacy Practices. Here is an online copy for your inspection. A copy of the form you will sign is explained below.