Radiation Oncology Department 1775 One Healing Place Tallahassee, FL 32308 Phone: (850) 431 – 5255 Fax: (850) 431 – 3989
Phillip V. Sharpe, M.D. Raj Bendre, M.D.
NEW PATIENT INTAKE FORM For referring Physicians: Please complete the following information. Please fax to Tallahassee Memorial Cancer Center Radiation Oncology Department (850) 431 – 3989 with a Diagnosis and appropriate records. Once received, we will schedule an appointment and fax this form back to you so your office can notify the patient of the appointment. Thank you for your assistance in advance.
Male / Female Patient Name: _____________________________________________ DOB: __________________________________ Address: __________________________________________________________________________________________ Home #: ____________________ Work #: ____________________ S.S.N. #: __________________________ Referring Physician: ________________________________ Contact Person: __________________________________ Phone: _______________________________________ Fax: _______________________________________ Diagnosis: ____________________________________ Diag. Code: __________________________________ Primary Care Physician: _________________________________ Contact Person: _______________________ Phone: ____________________________ Fax: __________________________ Insurance #1: ______________________________________ Policy #: ___________________________ Group #: ______________________________________ Referral #: ___________________________ Insurance #2: ______________________________________ Policy #: ___________________________ Group #: ______________________________________ Referral #: ___________________________ X-rays Where: ______________________________________ Date(s) ___________________________ CT/MRI/Other Where: _______________________________ Date(s) ___________________________ Pathology Where: ___________________________________ Date(s) ___________________________ COMMENTS: ____________________________________________________________________________________ ******************************************OFFICE USE ONLY *************************************** Date of Appointment: _________________ Time: ___________ Physician: _______________________________ Referring Physician Faxed: _______________________________ Confirmation: _______________________________ MRN ________________________ FIN _______________________ Authorization Received __________________
