Place Label Here

PATIENT MEDICAL HISTORY FORM

Dear Patient,

Please return completed packet with signature pages to the front desk.

Patient Name: _______________________________________________________________________________

DOB: ____/____/____ Age: __________ ❑ Male ❑ Female SS#:_____________________________________

Primary Address: _____________________________________________________________________________

City: ______________________________________________________ State:____________ Zip: ____________

Home Phone: ❑ Preferred (______) _______________________________________________________________

Cell Phone: ❑ Preferred (______) ________________________________________________________________

Secondary Address: ___________________________________________________________________________

City: _____________________________________________________ State: _____________ Zip: ____________

May we leave a message on your answering machine / voicemail? ❑ Yes ❑ No

Email Address: _____________________________________________ May we email you? ❑ Yes ❑ No

Preferred Language:____________________________________

Ethnicity: ❑ Hispanic/Latino ❑ Non-Hispanic/Latino

Race: ❑ Native American or Alaska Native ❑ Asian ❑ Black or African American ❑ Native Hawaiian or
Other Pacific Islander ❑ White ❑ Other

Pharmacy Name: _____________________________________________________________________________

Pharmacy Phone # and Cross Streets:_______________________________________________________________

(Internal Use Only)

MRN#: ______________

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Patient Name:____________________________________________________________ DOB:_______________

Primary Care Physician: _____________________________________________Phone: ____________________

Referring Physician (if different):________________________________________Phone: ____________________

Please list any additional Physicians you see: (Include Phone #):
_________________________________________________________________Phone:_____________________

_________________________________________________________________Phone:_____________________

_________________________________________________________________Phone:_____________________

_________________________________________________________________Phone:_____________________

Emergency Contact Name:

___________________________________________________________________________________________

Relationship: ________________________________________________Phone: (______) ___________________

Employment Status:

❑ Employed/Self Employed ❑ Unemployed ❑ Retired ❑ Disabled

Occupation (or Former Occupation):_______________________________________________________________

Name of Employer: ______________________________________ Work Phone: (______) ___________________

Advanced Directives:

Living Will ❑ Yes ❑ No ❑ Unknown Durable Power of Attorney ❑ Yes ❑ No ❑ Unknown

DNR ❑ Yes ❑ No ❑ Unknown

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Patient Name:______________________________________________________ DOB:__________________

Reason for this Visit:________________________________________________________________________

Medical History: Check the items that apply to you (current or past)

None ❑ Enlarged Prostate ❑ Leukemia ❑

Asthma ❑ Peripheral Vascular Disease (PVD) ❑ Anxiety ❑
Chronic Lung (COPD) ❑ Diabetes ❑ Problems with Anesthesia ❑
Pneumonia/Bronchitis ❑ Lupus-Autoimmune ❑ Thyroid Disease ❑
TB (Tuberculosis) ❑ Reynaud’s Syndrome ❑ High Blood Pressure ❑
Sleep Apnea ❑ Rheumatoid Arthritis ❑ High Cholesterol ❑
Colon Polyps ❑ Osteoarthritis ❑ Atrial Fibrillation (Afib) ❑
Crohn’s Disease ❑ Chronic Back Pain ❑ Congestive Heart Failure ❑
Diverticulitis ❑ Osteoporosis ❑ Heart Attack-MI ❑
Irritable Bowel Syndrome (IBS) ❑ Fracture ❑ Heart Disease ❑
Ulcerative Colitis ❑ Stroke ❑ Rheumatic Fever ❑
Stomach Ulcers ❑ Neuropathy ❑ Heartburn/Reflux ❑
GERD/Heartburn ❑ Parkinson’s Disease ❑ Heart Murmur ❑
Hiatal Hernia ❑ Paralysis ❑ Irregular Heart Beat ❑
Gallstones ❑ Seizures ❑ Frequent Infections ❑
Cirrhosis of Liver ❑ Migraines ❑ Blood Disorder ❑
Hepatitis A/ B/ C ❑ Shingles ❑ Blood Clots ❑
Pancreatitis ❑ Glaucoma/Cataracts ❑ Anemia ❑
Kidney Stone ❑ Hearing Loss ❑ Bleeding Disorder ❑
Kidney Disease/Failure ❑ Cancer ❑ Drug Use ❑
Freq. Urinary Tract Infections ❑ Lymphoma ❑ Depression ❑
(UTI)

Other Medical History: _____________________________________________________________________

Cancer History:

Type: _______________________________________________ Date diagnosed________________________

Treatment: (type, date, and location of treatment) __________________________________________________

________________________________________________________________________________________

Treating Physician: _________________________________________________________________________

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Patient Name:______________________________________________________ DOB:_____________________

Past Surgical History: (Please circle and date any of the surgeries and/or procedures that you have undergone)
Coronary Bypass Date:_________________ Knee Replacement Date:_________________
Angioplasty Date:_________________ Rotator Cuff Repair Date:_________________
Pacemaker Date:_________________ Cataract Date:_________________
Cardiac Valve Surgery Date:_________________ Gallbladder Surgery Date:_________________
Hemorrhoidectomy Date:_________________ Hysterectomy Date:_________________
Prostate Operation Date:_________________ Prostatectomy Date:_________________
Hernia Repair Date:_________________ Appendectomy Date:_________________
Tonsillectomy Date:_________________ Hip Replacement Date:_________________
Mastectomy Date:_________________ Lumpectomy Date:_________________
Other Operations:______________________________________________________________________

Social History:
Tobacco Use: (Present and/or Past):
❑ Never Smoked
❑ Quit smoking When? ________ How many years did you smoke? ______yr(s)
How many packs? ______/day
❑ Currently Smoke ❑ Cigarettes ❑ Pipe ❑ Cigars How many packs? _____/day
How many years?_________
❑ Chewing Tobacco

Alcohol History: (Present and/or Past):

❑ Non Drinker
❑ Beer number of bottles__________per ❑ Day ❑ Week ❑ Month
❑ Wine number of glasses__________per ❑ Day ❑ Week ❑ Month
❑ Liquor number of glasses __________per ❑ Day ❑ Week ❑ Month

Marital Status: ❑ Married ❑ Single ❑ Widowed ❑ Divorced ❑ Other

Household Status: ❑ Lives Alone ❑ Lives with Family ❑ Lives in Nursing Home
❑ Winter Resident ❑ Year-Round Resident
Children: ❑ Yes ❑ No Number _____

Health Maintenance:
Sigmoidoscopy / Colonoscopy: Yes No Date:____________
Findings:______________________________________________________________________________________
Last Mammogram: Date:___________ Last Bone Density: Date:___________ Last Pelvic Exam: Date:______________
Influenza (Flu) Shot: Date:__________ Pneumococcal Shot: Date:__________ Last Shingles Shot: Date:_____________
Last EGD: Date:_________________ Last Colonoscopy: Date:____________ Last Prostate Exam: Date:____________

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Patient Name:______________________________________________________ DOB:_____________________

Review of Symptoms: (Please check any current symptoms you have.)

General: Gastrointestinal: Psychiatric:
❑ Weight Loss ❑ Difficult or Painful Swallowing ❑ Anxiety/Agitation
How much ______________ ❑ Abdominal Pain ❑ Depression
Over what time period _________________ ❑ Nausea ❑ Crying for No Reason
❑ Fevers ❑ Vomiting ❑ Insomnia
❑ Max temp __________ ❑ Heartburn ❑ Alcoholism
❑ Chills ❑ Indigestion ❑ Drug Problem
❑ Night sweats ❑ Lump or Sensation in Throat
❑ Fatigue ❑ Food Sticking Hematologic:
❑ Bloating ❑ Easy Bruising
Eyes: ❑ Belching ❑ Gum or Nose Bleeding
❑ Wear Glasses/Contact Lenses ❑ Diarrhea ❑ Blood Transfusions
❑ Blurred Vision ❑ Constipation
❑ Double Vision ❑ Rectal Bleeding Endocrine:
❑ Black or Tarry Stool ❑ Heat or Cold Intolerance
Ears, Nose, Throat: ❑ Hidden Blood in Stool ❑ Excessive Skin Dryness
❑ Hard of Hearing or Deaf ❑ Excessive Rectal Gas/Flatus ❑ Excessive Thirst
❑ Ringing in Ears ❑ Loss of Stool/Fecal Accident ❑ Excessive Urination
❑ Enlarged Lymph nodes ❑ Poor Appetite ❑ Weight Problem
❑ Chronic Sinus Problems ❑ Jaundice ❑ Hot Flashes
❑ Sore Throat
❑ Mouth Pain/Sores Genitourinary: Breast:
❑ Kidney Stones ❑ Rashes or Itching
Changes/Difficulty In: ❑ Pelvic Pain ❑ Changing in Skin Color
❑ Taste ❑ Incontinence ❑ Varicose Veins
❑ Smell ❑ Burning or Pain on Urination ❑ Skin Cancer
❑ Blood in Urine ❑ Breast Pain/Lump
Cardiovascular: ❑ Difficult Urination ❑ Breast Discharge
❑ Chest Pain/Angina Pectoris ❑ Men: Prostate Problems ❑ Breast Rash
❑ Palpitations/Heart Murmur
❑ Irregular Heart Beat/Pressure Musculoskeletal: Allergies/Immunology:
❑ Joint Pain/Arthritis ❑ History of Allergies
Respiratory: ❑ Muscle or Joint Weakness ❑ Chronic Infections
❑ Chronic or Frequent Cough ❑ Back Pain
❑ Bloody Sputum ❑ Bone Pain
❑ Shortness of Breath ❑ Muscle Aches

Skin: Neurological:
❑ Rashes or Itching ❑ Numbness/Tingling
❑ Change in Skin Color or Moles ❑ Arm or Leg Weakness
❑ Varicose Veins ❑ Light-Headed/Dizzy/Fainting Spells
❑ Skin Cancer ❑ Tremors/Headaches

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Patient Name:______________________________________________________ DOB:_____________________

Family Medical History: Indicate any family members with cancer, blood disease or other disease.

Age Disease If deceased, cause of death

Father: _________________ ____________________ ________________________________
Mother: _________________ ____________________ ________________________________
Siblings: ___________________ ______________________ ___________________________________
___________________ ______________________ ___________________________________
___________________ ______________________ ___________________________________

MEDICATION LIST

Your treatment can be affected by any medication that you take, and it is important that your physician has updated
and correct information.

Drug Allergies: List all medication allergies

Medication:_________________________________ Reaction:________________________________
Medication:_________________________________ Reaction:________________________________
Medication:_________________________________ Reaction:________________________________
Medication:_________________________________ Reaction:________________________________

Are you allergic to:

❑ Iodine ❑ Latex ❑ Shellfish ❑ CT Scan Dye / IV Contrast ❑ Eggs ❑ Peanuts

Other:________________________________________________________________________________
Type of Reaction:________________________________________________________________________

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Patient Name:______________________________________________________ DOB:_____________________

CURRENT MEDICATION LIST

List all medications (including non-prescription) that you are currently taking:

Medication Dose Frequency Ordering Physician

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 AUTHORIZATION AND RELEASE TO BE PHOTOGRAPHED
FOR ELECTRONIC MEDICAL RECORDS

I authorize Summit Cancer Centers (SCC/AOP), a division of American Oncology Partners, P.A. (SCC/AOP), to take
my photograph (digital camera/video may be used). These photos may then be placed in my SCC/AOP electronic
medical record for identification purposes and/or medical documentation.

By signing this, I verify that I have received a copy of this authorization form for my records.

Patient Name (Print)

Patient or Guarantor (Signature)

Date

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 REQUEST FOR RELEASE OF RECORDS

I, ____________________________________________, request a copy of my complete medical record from the

office of:

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Name and address of practitioner

To be sent to Summit Cancer Centers: (Internal use)

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Address, City, State, Zip Code

––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
Fax/Telephone Number

______ I give permission to release my medical records to the above listed person, company or medical facility.
I understand that my records will be sent via telephone communication.

It is my understanding that by signing this authorization for release of my records, I am giving permission for
Summit Cancer Centers (SCC/AOP) to receive copies of any medical, psychiatric, AIDS, AIDS-related syndromes, HIV
testing, alcohol and/or drug abuse related information for the above listed person(s) or organization. I also understand
that this authorization may be revoked at any time except to the extent action has been taken prior to
revocation. This consent is valid indefinitely until there is written communication received to revoke.

_______DISCLAIMER: Not signing does not prevent me from receiving care.

_____________________________________________________________ ____________________
Patient Name (Print) Date

_____________________________________________________________
Patient Date of Birth

_____________________________________________________________ ____________________
Patient or Guarantor (Signature) Date

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 CONSENT TO DISCLOSE MEDICAL INFORMATION

Patient Name:______________________________________________________ DOB:_____________________

Please check one of the following:

______ I give permission to the employees of Summit Cancer Centers (SCC/AOP), a division of American Oncology
Partners, P.A. to disclose my Protected Health Information to me and the following individual(s):

Name:____________________________________________ Relation:_______________ Phone:_____________

Name:____________________________________________ Relation:_______________ Phone:_____________

Name:____________________________________________ Relation:_______________ Phone:_____________

Name:____________________________________________ Relation:_______________ Phone:_____________

Name:____________________________________________ Relation:_______________ Phone:_____________

Name:____________________________________________ Relation:_______________ Phone:_____________

______ I request that all my Protected Health Information be disclosed ONLY to me and no other individual(s).

I understand that I may revoke or change this Consent at any time by filling out another Consent form to replace
this one.

Patient Name (Print) Date

Patient or Guarantor (Signature)

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Patient Name:_____________________________________________ DOB:_____________________________

INSURANCE INFORMATION
Primary Insurance Carrier:____________________________________________________________________

Name of primary policy holder:__________________________________________________________________

Policy#/Group ID:____________________________________________________________________________

Policy holder’s date of birth:_______________________________ Policy holder’s SS#:______________________

Policy holder’s employer:_______________________________________________________________________

Does plan have prescription coverage? ❑ Yes ❑ No

Secondary Insurance Carrier:___________________________________________________________________

Name of secondary policy holder:________________________________________________________________

Policy#/Group ID:____________________________________________________________________________

Policy holder’s date of birth:_______________________________ Policy holder’s SS#:______________________

Policy holder’s employer:_______________________________________________________________________

Does plan have prescription coverage? ❑ Yes ❑ No

Pharmacy Insurance Carrier: ____________________________

Name of pharmacy policy holder:___________________________

Policy#/Bin# _____________________

I certify that the information provided is accurate. I will notify Summit Cancer Centers (SCC/AOP), a division
of American Oncology Partners, P.A. of any changes as soon as they become available. I understand that it is my
responsibility to update us of any changes to my insurance plan or I may be held liable for the full balance of my
treatment.

_______________________________________________________________ ___________________
Patient Name (Print) Date

_______________________________________________________________ _
Patient or Guarantor (Signature)

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 FINANCIAL POLICIES AGREEMENT
Dear Valued Patient,

Thank you for choosing Summit Cancer Centers, a division of American Oncology Partners, P.A. (SCC/AOP), as your
health care provider. Our physicians are committed to providing you with the highest quality care.

Prior to receiving treatment, please read and acknowledge our patient financial policies:
• You agree to provide SCC/AOP with current and accurate insurance, health care benefits program and/or other payer
information, and to immediately notify us if your coverage changes.
• You agree that these policies apply to you, and may change from time to time without notice.
• You acknowledge that SCC/AOP will bill your insurance plan or program for services provided by SCC/AOP and you
agree you are assigning your right to receive payment or benefits from such insurer or program to SCC/AOP and you are
authorizing payment to be made directly to SCC/AOP.
• You agree you are responsible for payment to SCC/AOP of all co-pays, deductibles and co-insurance applicable under
your insurance policy, plan or program. You understand that payment of such amounts is due at the time
of service.
• Depending on your insurer, plan or program, some services may not be covered. If your insurance does not authorize
or cover a service or treatment and you nevertheless decide to receive such service or treatment, you agree that you
are responsible for payment. This applies to all payers in accordance with all applicable law and regulation and payer
requirements (including any “advance beneficiary notice” (ABN) which may be applicable under Medicare).
• To facilitate payment of claims, to perform internal operations and to coordinate your care with other health care
providers, SCC/AOP will use your personal health information internally and will share such information with your
insurance policy and certain business associates of SCC/AOP in accordance with the Health Insurance Portability and
Accountability Act of 1996 (HIPAA) and other applicable federal and state law and regulation.
• SCC/AOP owns and operates AON Pharmacy, LLC, a specialty pharmacy that provides certain pharmaceuticals that
may be prescribed by your SCC/AOP physician and may be covered under your medical or pharmacy benefits plan
or program (such as Medicare Part B or Part D). You are not obligated to use AON Pharmacy, LLC and may have
your prescriptions filled wherever you choose. However, if you select AON Pharmacy, LLC to fill SCC/AOP-issued
prescriptions, then this policy and all other SCC/AOP patient financial responsibility policies will also apply to the items
and services provided to you by AON Pharmacy, LLC.
• You acknowledge that laboratory and/or radiology services may be necessary as part of your care and treatment
which may be performed by SCC/AOP clinicians at SCC/AOP’s own facilities. In some cases, services may be provided by
outside facilities, in which case, you understand that you may receive a separate bill directly from the outside provider.
• If you make a payment to SCC/AOP that results in a surplus on your account (e.g., a credit balance), SCC/AOP may
hold that amount as a deposit against charges that are subject to ongoing claims processing or charges for scheduled
future services, and SCC/AOP may apply the surplus against such pending or future scheduled charges. If a surplus
still remains after applying all credits, or if at the conclusion of your care a credit balance remains which is not subject
to return to your insurer or other payer, SCC/AOP will refund the credit balance to you. However, you agree that any
refund under $10.00 will be made only if you make a written request and, in any event, any credit balance under $10.00
will be forfeited if a refund request is not received within five (5) years after the conclusion of your care.

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I HAVE READ, UNDERSTAND AND AGREE TO THE ABOVE PATIENT FINANCIAL POLICIES.
A COPY IS AVAILABLE TO THE PATIENT UPON REQUEST

Patient Name (Print) Date

Patient or Guarantor (Signature)

For office use:

Name (Print)

SCC/AOP Employee (Signature)

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 MEDIGAP
Only applicable for patients with secondary insurance to Medicare

Name of Beneficiary: ___________________________________________________________________

Health Insurance Claim Number: _________________________________________________________

Medicare Beneficiary Identifier: __________________________________________________________

Medigap Policy Number: ________________________________________________________________

I request that payment of authorized Medigap benefits be made on my behalf to Summit Cancer Centers, a division of
American Oncology Partners, P.A., (SCC/AOP) or AON Pharmacy, LLC for any services furnished by
__________________________________________. I authorize any holder of medical information about me to
Physician Name
release to _____________________________________ any information concerning this Medicare claim, because
Insurance Name
my signing this authorization will cause Medicare payment information to cross over automatically.

Patient Name (Print) Date

Patient or Guarantor (Signature)

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 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

By signing this form, you acknowledge that you have received or have been informed that you have the right to
receive a copy of the Summit Cancer Centers, a division of American Oncology Partners, P.A., (SCC/AOP) Notice of
Privacy Practices.

This notice is available in hard copy by verbally requesting a copy at the front desk of any Summit Cancer Centers,
a division of American Oncology Partners, P.A., (SCC/AOP) facility or by submitting a request in writing to the
corporate office at Summit Cancer Centers, a division of American Oncology Partners, P.A., (SCC/AOP), 9160
Forum Corporate Parkway, Suite 350, Fort Myers, FL 33905.
You may also view and/or print a copy of the Notice of Privacy Practices by visiting AONcology.com/policies/SCC_NPP.pdf

Date:_______________

Patient Name (Print) DOB

Patient (Signature) Date

Patient or Guarantor (Signature) Date

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By signing below, I authorize Summit Cancer Centers, a division of American Oncology Partners, P.A., (SCC/AOP)
its affiliate and subsidiary entities, and AON Pharmacy, LLC (and any authorized SCC/AOP texting service vendor)
to contact me by SMS text message for health-related notifications, including appointment reminders and billing
communications.

I understand that message/data rates may apply to messages sent by SCC/AOP under my cell phone plan.

I know that I am under no obligation to authorize SCC/AOP to send me text messages. I may opt-out of receiving
these communications at any time by responding with “STOP”.

I understand that text messages are not a substitute for professional or medical attention.

By signing below, I indicate I am the person legally responsible for all use of mobile accounts, that I am at least 18
years of age, and that I agree to all terms and conditions of use for the text messaging services.

PLEASE MARK THE FOLLOWING:

❑ I consent to receiving information via text. I understand I can withdraw my consent at any time.
Text Cell #____________

❑ I do not consent to receiving any information via text. I understand that I can change my mind and provide
consent later.

Patient Name (Print) Date

Patient (Signature)

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