The Center for Cancer and Blood Disorder new patient forms

CCBD requires new patients to complete certain forms so that we have complete information before beginning treatment.  Please click on each of the forms listed below and print out its PDF file.  Then complete each one and bring it with you to your first appointment.  

Required Forms and Documents:

New Patient Welcome Letter
Office Guide
Medical Release Form
Health Questionnaire
Patient Information Questionnaire
HIPAA Privacy Practices
Telephone Policy
Financial Responsibility
M-Pay Service
 

Also, bring to your first appointment:

Along with the completed forms, please bring with you to your first appointment:
  • a list of ALL your current medications
  • your medical insurance card(s)
  • your driver's license or a photo ID
  • your referral form (if required by your insurance company)
  • a method of payment (cash, check, Visa, or MasterCard)

Your Medical Records

Prior to your appointment, our Medical Records Department will contact your primary and referring doctors to obtain your medical records.  We need these records to ensure that we give you proper care.  Your primary physician may require a signed Authorization for Use or Disclosure of Protected Health Information form (a medical release form), so we have included one for your convenience.  Simply sign it and forward it to your primary doctor.  Feel free to make copies of the form if your other healthcare providers also require authorization.

Changes to Your Information

 If your address, phone number, or insurance information changes, please let us know.   Call our Front Desk at 301.571.0019.