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Florida Hospital Form in PDF

The Florida Hospital form serves as a comprehensive intake document for new patients seeking oncology services. It collects essential patient information, including demographics, insurance details, and medical history, to facilitate timely scheduling of appointments with specialized oncologists. By streamlining the referral process, this form aims to enhance patient care and ensure that individuals receive the attention they need within a targeted timeframe.

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The Florida Hospital form is a crucial document designed to streamline the patient intake process for oncology services. This form facilitates the scheduling of appointments with various specialists, including hematology, medical oncology, radiation oncology, and surgical oncology. Patients are required to provide essential personal information, such as their name, address, date of birth, and social security number, along with details about their primary and secondary insurance coverage. The form also prompts patients to indicate the urgency of their appointment, specifying whether it is for a new diagnosis, disease progression, or a second opinion. Additionally, it requests information from the referring physician, including necessary medical records and documentation to expedite the referral process. To ensure a timely appointment, patients are encouraged to submit the completed form and required documents via email or fax. The form also includes sections for the cancer center scheduler to input patient information, appointment details, and records received, thereby maintaining an organized system for patient care. By providing clear instructions and a comprehensive structure, the Florida Hospital form aims to enhance the overall patient experience while ensuring that individuals receive timely and appropriate medical attention.

Form Example

New Patient Intake Form V1.1 Every attempt is made to see the patient within 3-5 days from receipt of the referral request.

Schedule Appointment with:		Date/Time:
		Date/Time:

	Dr. Seema Harichand-Herdt-Hematology Oncology	Dr. Michael Kelley-Medical Oncology



	Dr. Ronald Krochak-Radiation Oncology	Dr. Christopher Windham-Surgical Oncology

Patient Information

First Name:

Address:

Last Name:

City:

State:

Zip:

Date of Birth:

Primary

Secondary

Phone:

Social Security #:

Home	Cell	Work	Home	Cell	Work	Female	Male	Race:
					Primary Insurance

Insurance Company Name & Phone Number:

Subscriber’s Name:

Policy #:

Group #:

Subscriber’s DOB:

Subscriber’s SSN:

Female

Male

Secondary Insurance

Insurance Company Name & Phone Number:

Subscriber’s Name:

Policy #:

Group #:

Subscriber’s DOB:

Subscriber’s SSN:

Female

Male

Urgent

Appointment?

**Needs to be seen

Reason for Appointment:

Diagnosis

within 24-48 from

receipt of referral

New Diagnosis

Disease Progression

Yes

2nd Opinion

Referring Physician

Primary Care Physician

Name & Phone Number:

Comments

Please email the completed form to oncologyscheduling@fhmmc.org Questions: (386) 231-4050. In order to expedite the referral and allow us to see your patient in our 3-5 day timeframe, please send the below records to the above email or via fax (386) 231- 4001. A blank version of this form can be downloaded at www.floridahospitalmemorial.org/cancer.


	Required Documents from Referring Physician Office
Demographics	History & Physical	Operative Report(s)	CT Scan(s)	Ultrasound(s)	Mammogram(s)	Recent Labs
Insurance Info	Path Report(s)	PET Scan(s)	MRI(s)	Bone Scan	Plain Films(s)	Office Notes

Patient Label

THIS SECTION TO BE COMPLETED BY THE CANCER CENTER SCHEDULER

PATIENT INFORMATION

First Name:

Last Name:

APPOINTMENT DATE/TIME

CARE NAVIGATORS NOTIFIED

Breast Care Navigator

Appt Date:

Appt Time:

Lung Care Navigator

PATIENT AND APPOINTMENT ENTERED INTO SYSTEM

Radiation Oncology (Dr. Krochak)

Dr. Harichand, Dr. Kelley, Dr. Windham

MR #

FIN#

NextGen-Health Care Partners Oncology

NextGen-Health Care Partners

Cerner Scheduling

IMPAC

ARIA

PATIENT NOTIFIED

NEW PATIENT PACKET GIVEN TO PT

Date/Time Patient Notified:

CCC General Pt Packet

CW-General CW-Breast

CW-GI

CW-Skin

CW-Soft Tissue

CW-Port Placement

Mailed

Date/Time:

Spoke directly to patient

Spoke with patients family

Emailed

Email Address

RECORDS RECEIVED FROM REFERRING PHYSICIAN

Date:

Pathology Report

Operative Report

Applicable Consultation Reports

Bone Scan

History & Physical

Most Recent Blood Work (Labs)

CT Scan

Time:

Initials:

PET Scan

MRI

Mammogram

Ultrasound

CHART CREATED

Radiation Oncology (Dr. Krochak)

Dr. Harichand, Dr. Kelley, Dr. Windham

Chart Label printed (Name & MRN)

Chart Label printed (Name & DOB)

Facesheet & Labels printed from Cerner

Records in chart

CHART FORWARDED TO NURSING

NURSING RECEIVED

Date/Time:

Initials:

Date/Time:

Initials:

Notes

⇩ Florida Hospital File

Document Breakdown

Fact Name	Description
Form Title	The form is titled "New Patient Intake Form V1.1," indicating it is designed for new patients at Florida Hospital.
Appointment Timeline	Patients are typically seen within 3-5 days of the referral request, ensuring timely care.
Contact Information	For questions or to submit the form, patients can call (386) 231-4050 or email oncologyscheduling@fhmmc.org.
Required Documents	Referring physicians must provide specific documents, including history & physical, lab results, and imaging reports.
Insurance Information	The form collects details about primary and secondary insurance, including subscriber information and policy numbers.
Governing Laws	This form adheres to Florida state laws regarding patient privacy and healthcare documentation, including HIPAA regulations.

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