Dear Patient,
We hope your visit is pleasant, and to make
things go more smoothly, we have included a New Patient Welcome Packet for your
benefit. Please complete the following enclosed forms:
allows us to accept payment from your insurance.
gives us permission to obtain your records
from your other providers/hospitals. This form is provided for your convenience. Should you
need to request records for another provider in the future, bring this form to the front desk
at our office.
indicates to whom we can release your medical information.
a form that is required by new health care standards
includes questions regarding your past medical
history. Please fill out this form as completely as possible, as it is a valuable tool for
your physician.
In addition to the above, completed forms, please bring the following with you to your
appointment:
include over the counter and herbal drugs. In
lieu of a list, you may bring in your pill bottles.
referral from primary care
physician when necessary
Name, address, and phone number.
welcomes your friends or loved ones to visit
during your treatment. Together, we share a common desire to create a safe and
comfortable environment for your treatment or office visit. For the safety of our
patients and staff, Illinois Cancer Specialists asks that you limit visitors to 1-2 people
and do not allow children in the lab or treatment areas. Children must remain in the
main lobby area and accompanied by a parent or guardian at all times. Thank you for
your cooperation.
You will find answers to many questions you may have in the “General Information”
handout; however, should you have questions which are not addressed, feel free to
call our office or ask any staff member during your visit.
Sincerely,
12032902 Packet.indd 1 6/8/12 12:24 PM
Dear Patient,
We hope your visit is pleasant, and to make
things go more smoothly, we have included a New Patient Welcome Packet for your
benefit. Please complete the following enclosed forms:
allows us to accept payment from your insurance.
gives us permission to obtain your records
from your other providers/hospitals. This form is provided for your convenience. Should you
need to request records for another provider in the future, bring this form to the front desk
at our office.
indicates to whom we can release your medical information.
a form that is required by new health care standards
includes questions regarding your past medical
history. Please fill out this form as completely as possible, as it is a valuable tool for
your physician.
In addition to the above, completed forms, please bring the following with you to your
appointment:
include over the counter and herbal drugs. In
lieu of a list, you may bring in your pill bottles.
referral from primary care
physician when necessary
Name, address, and phone number.
welcomes your friends or loved ones to visit
during your treatment. Together, we share a common desire to create a safe and
comfortable environment for your treatment or office visit. For the safety of our
patients and staff, Illinois Cancer Specialists asks that you limit visitors to 1-2 people
and do not allow children in the lab or treatment areas. Children must remain in the
main lobby area and accompanied by a parent or guardian at all times. Thank you for
your cooperation.
You will find answers to many questions you may have in the “General Information”
handout; however, should you have questions which are not addressed, feel free to
call our office or ask any staff member during your visit.
Sincerely,
12032902 Packet.indd 1 6/8/12 12:24 PM
In addition
to the completed forms in your welcome packet,
please bring the following items with you to your
appointment:
1. List of your questions or concerns
2. Your current medications (including over-
the-counter and herbal medications) - please
bring either a list or the actual bottles
3. Current insurance and prescription cards
4. Your preferred pharmacy information: name,
address, and phone number
Please leave a detailed message
with your full name (including the spelling of
your last name), date of birth, reason for calling,
and a number where you can be reached. Every
effort will be made to return your call as soon
as possible, and our goal is to return your call
the same day. If it is important that your call
be returned within a certain amount of time
(example; need a call back within 2 hours) you
must make that clear in your message.
This
restriction is for your protection: we must be
able to have access to your most up-to-date and
complete medical records to ensure you receive
appropriate medications and approvals from
your physician.
1. Full name (including spelling of last name)
2. Date of birth for the patient
3. Phone number where you can be reached
Please call the office and speak with the nurse
before coming in for an unscheduled visit. We will
always accommodate emergencies when they
occur. For this reason it is very important to
always schedule your visits so that time can be
set aside for your care.
If you cannot keep a scheduled appointment
please let us know as soon as possible so that
we can release that time for another patient.
Please pay close attention to your appointment
time and help us by arriving at the time
designated on your appointment card. Please
understand that in order to be respectful of those
patients who do arrive at their scheduled times,
late arrivals will be worked into the schedule as
it allows. Additionally, those who arrive more
than 30 minutes before their appointment will
be asked to wait.
A day
or two prior to your first appointment with our
office, a registration clerk will contact you to
obtain and verify your insurance information.
It is a requirement of your health insurance
that co-payments be collected at each visit.
We participate with most major insurance
carriers. As a courtesy, claims will be filed for
you. In order to ensure reimbursement, your
insurance information must be kept current.
Please remember that your insurance policy
is a contract between you and your insurance
company and we are not a party to the
contract. For your convenience we accept Visa,
MasterCard, Discover, and American Express.
If there is a patient responsibility due, you will
receive monthly statements showing you an
itemization of charges and payments made
by you or your insurance company. You will
be introduced to one of our Patient Financial
Counselors who will assist you with your
financial health.
If you have questions regarding your billing,
do not hesitate to contact our billing office at
(847) 585-7000.
There you can explore the
Resource Center, get directions, and find valuable
links to other websites.
If you have any questions, at any time, do not
hesitate to ask a ICS staff member or call our
offices where we will be happy to assist you.
12032902 Packet.indd 2 6/8/12 12:24 PM
In addition
to the completed forms in your welcome packet,
please bring the following items with you to your
appointment:
1. List of your questions or concerns
2. Your current medications (including over-
the-counter and herbal medications) - please
bring either a list or the actual bottles
3. Current insurance and prescription cards
4. Your preferred pharmacy information: name,
address, and phone number
Please leave a detailed message
with your full name (including the spelling of
your last name), date of birth, reason for calling,
and a number where you can be reached. Every
effort will be made to return your call as soon
as possible, and our goal is to return your call
the same day. If it is important that your call
be returned within a certain amount of time
(example; need a call back within 2 hours) you
must make that clear in your message.
This
restriction is for your protection: we must be
able to have access to your most up-to-date and
complete medical records to ensure you receive
appropriate medications and approvals from
your physician.
1. Full name (including spelling of last name)
2. Date of birth for the patient
3. Phone number where you can be reached
Please call the office and speak with the nurse
before coming in for an unscheduled visit. We will
always accommodate emergencies when they
occur. For this reason it is very important to
always schedule your visits so that time can be
set aside for your care.
If you cannot keep a scheduled appointment
please let us know as soon as possible so that
we can release that time for another patient.
Please pay close attention to your appointment
time and help us by arriving at the time
designated on your appointment card. Please
understand that in order to be respectful of those
patients who do arrive at their scheduled times,
late arrivals will be worked into the schedule as
it allows. Additionally, those who arrive more
than 30 minutes before their appointment will
be asked to wait.
A day
or two prior to your first appointment with our
office, a registration clerk will contact you to
obtain and verify your insurance information.
It is a requirement of your health insurance
that co-payments be collected at each visit.
We participate with most major insurance
carriers. As a courtesy, claims will be filed for
you. In order to ensure reimbursement, your
insurance information must be kept current.
Please remember that your insurance policy
is a contract between you and your insurance
company and we are not a party to the
contract. For your convenience we accept Visa,
MasterCard, Discover, and American Express.
If there is a patient responsibility due, you will
receive monthly statements showing you an
itemization of charges and payments made
by you or your insurance company. You will
be introduced to one of our Patient Financial
Counselors who will assist you with your
financial health.
If you have questions regarding your billing,
do not hesitate to contact our billing office at
(847) 585-7000.
There you can explore the
Resource Center, get directions, and find valuable
links to other websites.
If you have any questions, at any time, do not
hesitate to ask a ICS staff member or call our
offices where we will be happy to assist you.
12032902 Packet.indd 2 6/8/12 12:24 PM
Our medical oncology team plays a major
role in cancer care by managing treatment
plans and therapies, monitoring and
evaluating progress, and collaborating
on best options with other caregivers.
We consult with patients on their choices
and any temporary side effects they
may experience during chemotherapy
treatments, as well as offer medical
guidance to help patients make decisions
along the way.
Our hematology team has extensive
experience providing high quality
patient care, research, and leading-edge
treatment of blood and bone marrow
disorders; for both cancer and non-cancer
patients.
These ICS physicians are trained in the
specialties of both medical oncology and
hematology.
Dr. Lisa Baddi
Dr. Susan G. Brown
Dr. John W. Eklund
Dr. David Hakimian
Dr. Prashant K. Joshi
Dr. Bruce R. Kaden
Dr. Leonard M. Klein
Dr. Rajat Malhotra
Dr. Randy S. Rich
Dr. Christopher G. Rose
Dr. Joel Schwartz
Dr. Richard S. Siegel
Today, radiation therapy is quicker, safer
and more precise than ever before. Our
radiation oncology team uses advanced
treatment planning systems and state-of-
the-art radiation technology to deliver
internal and external radiation to
cancerous cells, which helps prevent them
from growing or dividing and spreading.
Dr. Joel Schwartz
Many of our sites have at least one Nurse
Practitioner or Physicians Assistant on
site. Patients may interface with them in
between physician visits.
Often described as an art and a science,
nursing is a critical link between our
patients and physicians. Our nurses have
many roles, from educator to practitioner
and researcher, and serve all of them
with passion for the profession and with a
strong commitment to patient safety.
880 West Central Road
Suite 8200
Arlington Heights, IL 60005
(847) 259-4482
7447 W. Talcott Ave.
Suite 400
Chicago, IL 60631
(773) 763-9300
8915 W. Golf Road
Niles, IL 60714
(847) 827-9060
With many years of experience caring for cancer patients, our physicians, nurses,
pharmacists, counselors and other specialists work together to provide world-class,
personalized cancer care.
12032902 Packet.indd 3 6/8/12 12:24 PM
Our medical oncology team plays a major
role in cancer care by managing treatment
plans and therapies, monitoring and
evaluating progress, and collaborating
on best options with other caregivers.
We consult with patients on their choices
and any temporary side effects they
may experience during chemotherapy
treatments, as well as offer medical
guidance to help patients make decisions
along the way.
Our hematology team has extensive
experience providing high quality
patient care, research, and leading-edge
treatment of blood and bone marrow
disorders; for both cancer and non-cancer
patients.
These ICS physicians are trained in the
specialties of both medical oncology and
hematology.
Today, radiation therapy is quicker, safer
and more precise than ever before. Our
radiation oncology team uses advanced
treatment planning systems and state-of-
the-art radiation technology to deliver
internal and external radiation to
cancerous cells, which helps prevent them
from growing or dividing and spreading.
Dr. Joel Schwartz
Many of our sites have at least one Nurse
Practitioner or Physicians Assistant on
site. Patients may interface with them in
between physician visits.
Often described as an art and a science,
nursing is a critical link between our
patients and physicians. Our nurses have
many roles, from educator to practitioner
and researcher, and serve all of them
with passion for the profession and with a
strong commitment to patient safety.
With many years of experience caring for cancer patients, our physicians, nurses,
pharmacists, counselors and other specialists work together to provide world-class,
personalized cancer care.
12032902 Packet.indd 3 6/8/12 12:24 PM
Arlington Heights
880 West Central Road
Suite 8200
Arlington Heights, IL 60005
(847) 259-4482
Bolingbrook
396 Remington Blvd.
Suite 141
Bolingbrook, IL 60440
(630) 654-1790
Chicago/Resurrection
7447 W. Talcott Ave.
Suite 400
Chicago, IL 60631
(773) 763-9300
Elgin
1710 N. Randall Road
Suite 300
Elgin, IL 60123
(847) 931-0909
Hinsdale
908 North Elm Street
Suite 210
Hinsdale, IL 60521
(630) 654-1790
Hoffman Estates
1555 Barrington Road
Suite 235
Hoffman Estates, IL 60169
(847) 885-0909
Huntley
10350 Haligus Road
Suite 210
Huntley, IL 60142
(847) 802-7880
McHenry
4305 Medical Center Drive
Suite 1
McHenry, IL 60050
(815) 363-0066
Niles
8915 W. Golf Road
Niles, IL 60714
(847) 827-9060
Woodstock
3703 Doty Road
Suite 6
Woodstock, IL 60098
(815) 334-9154
Dr. Lisa Baddi
Dr. Susan G. Brown
Dr. Jay S. Dalal
Dr. Apurva Desai
Dr. John W. Eklund
Dr. David Hakimian
Dr. Prashant K. Joshi
Dr. Bruce R. Kaden
Dr. Leonard M. Klein
Dr. Arti A. Lakhani
Dr. Patricia J. Madej
Dr. Rajat Malhotra
Dr. Rajini Manjunath
Dr. Stan Nabrinsky
Dr. Randy S. Rich
Dr. Christopher G. Rose
Dr. Elyse C. Schneiderman
Dr. Joel Schwartz
Dr. Richard S. Siegel
Dr. Veerpal Singh
Dr. Donald L. Sweet
Dr. Christine S. Winter
Dr. C. Yeshwant
Dr. Aslam S. Zahir
Thanks to the dedication of our experienced physicians and staff,
Illinois Cancer Specialists provides unparalleled access to innovative therapies
and the latest technologies based on the latest clinical evidence—right here
in our community. From leading-edge diagnostic imaging and sophisticated
radiation therapies, to new investigational drugs through clinical trials, we offer
our patients advanced and comprehensive cancer care.
To us, providing comprehensive care also means understanding that having
cancer is hard on patients and their families. Our physicians and staff will do
whatever it takes to make everyone more comfortable. We will spend time
with our patients to make sure they understand their diagnosis and treatment
options, and offer educational resources and support services designed to help
patients and their families understand and cope with their disease.
Medical Oncology
Radiation Oncology
Hematology
Oncology Clinical Nursing
Stem Cell Transplantation
Hormone Therapy
Immunotherapy
Chemotherapy
PET/CT
Pharmacy
Clinical Laboratory Services
Clinical Studies/Research Trials
Therapeutic Phlebotomy
Genetic Testing
Genetic Counseling
Access to Clinical Social Worker
Patient Financial Counselors
Educational Resources
Home Care Support Referral
Hospice Care Referral
Palliative Care
12032902 Packet.indd 4 6/8/12 12:24 PM
Thanks to the dedication of our experienced physicians and staff,
Illinois Cancer Specialists provides unparalleled access to innovative therapies
and the latest technologies based on the latest clinical evidence—right here
in our community. From leading-edge diagnostic imaging and sophisticated
radiation therapies, to new investigational drugs through clinical trials, we offer
our patients advanced and comprehensive cancer care.
To us, providing comprehensive care also means understanding that having
cancer is hard on patients and their families. Our physicians and staff will do
whatever it takes to make everyone more comfortable. We will spend time
with our patients to make sure they understand their diagnosis and treatment
options, and offer educational resources and support services designed to help
patients and their families understand and cope with their disease.
Medical Oncology
Radiation Oncology
Hematology
Oncology Clinical Nursing
Stem Cell Transplantation
Hormone Therapy
Immunotherapy
Chemotherapy
PET/CT
Pharmacy
Clinical Laboratory Services
Clinical Studies/Research Trials
Therapeutic Phlebotomy
Genetic Testing
Genetic Counseling
Access to Clinical Social Worker
Patient Financial Counselors
Educational Resources
Home Care Support Referral
Hospice Care Referral
Palliative Care
12032902 Packet.indd 4 6/8/12 12:24 PM
AS A PAtIent I
HAVe tHe rIgHt
to reCeIVe An
exPlAnAtIon of my
dIAgnoSIS, BenefItS
of treAtment,
AlternAtIVeS,
reCUPerAtIon,
rISkS And An
exPlAnAtIon of
ConSeQUenCeS If
treAtment IS not
PUrSUed.
5
12032902 Packet.indd 5 6/8/12 12:24 PM
Today’s Date:
( )
Home Telephone
Cell ( )
Street
State Zip
Single Divorced Widowed Other
Check Marital Status
( )
Telephone
Occupation
( )
Telephone
( )
Telephone
Telephone:( )
Telephone
:( )
agree, in the event of non-payment, to assume the
OKED BY ME IN WRITING
.
l.
Date/Time
AM or PM (circle one)
Date/Time
AM or PM (circle one)
EMPLOYEE INITIALS
6/8/12 12:24 PM
Revised March 201
ASSIGNMENT OF BENEFITS/FINANCIAL RESPONSIBILITIES
Today’s Date:
Patient Name:
( )
Last First M.I. Home Telephone
Cell ( )
Home Address:
Mailing Address:
Street
Street
City State Zip City State Zip
DOB:
Age
M F
SS#
Married
Single
Divorced
Widowed
Other
Sex Check Marital Status
Employer
( )
Name
Telephone
Address
Occupation
Responsible Party:
( )
Name Relationship Telephone
Emergency Contact:
Spouse/Next of Kin:
( )
Name
Relationship
Telephone
Referring
Physician:
Primary Care
Physician:
Primary Ins:
Insured Name: _______________________ DOB _________
Secondary Ins:
Insured Name: _______________________ DOB _________
1. I understand that I am responsible for charges not covered or reimbursed by the above agents. I agree, in the event of non-payment, to assume the
costs of interest, collection and legal action (if required).
2. I authorize my insurance carrier to release information regarding my coverage to Illinois Cancer Specialists.
3. My right to payment for all pharmaceuticals, procedures, tests, medical equipment rentals, supplies and nursing/physician services including major
medical benefits are hereby assigned to Illinois Cancer Specialists. This assignment covers any and all benefits under Medicare, other government
sponsored programs, private insurance and any other health plans. I acknowledge this document as a legally binding assignment to collect my benefits
as payment of claims for services. In the event my insurance carrier does not accept Assignment of Benefits, or if payments are made directly to me or
my representative, I will endorse such payments to Illinois Cancer Specialists.
4. I understand that I have a right to request and receive a Notice of Privacy Practices from Illinois Cancer Specialists.
THIS AGREEMENT/CONSENT WILL REMAIN IN EFFECT UNLESS REVOKED BY ME IN WRITING.
I have read and received a copy of the above statements and accept the terms. A duplicate of the statement is considered the same as original.
Patient Signature
Date/Time
AM or PM (circle one)
Responsible Party Signature Relationship
Date/Time
AM or PM (circle one)
PHYSICIAN:
EMPLOYEE INITIALS
ACCT NBR: LOC:
FOR OFFICE USE ONLY
4
12032902 Packet.indd 6 6/8/12 12:24 PM
Illinois Cancer Specialists
HIPAA Authorization
In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and
disclosures of their protected health information (PHI). The individual is also provided the right to request
confidential communications or that a communication of PHI be made by alternate means, such as sending
correspondence to the individual’s office instead of the individual’s home.
Please indicate below your preferred method of contact.
o Home Phone ________________ Can we leave a detailed message? YES NO
o Cell Phone __________________ Can we leave a detailed message? YES NO
o Work Phone _________________ Can we leave a detailed message? YES NO
I authorize Illinois Cancer Specialists to release my medical information to person(s) listed
below. I understand that the person(s) named on this authorization will be given access to obtain
or review my medical information and have my permission to discuss my care or obtain
results/information on my behalf. I authorize the person(s) indicated below to pick-up materials
pertinent to my medical care.
Name Relationship Telephone#
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_________________________________________________ _____________________
Print
Patient Name Date of Birth
_________________________________________________ ________________
Patient Signature Date
I do not authorize release or disclosure to my spouse, family member, or personal representative at this time. I may review this decision in
writing at a later date, if I so choose.
___________________________________ ____________________ ____________________________
Print Patient Name Date Date of Birth
The privacy rule generally requires healthcare providers to take reasonable steps to limit the use or disclosure of,
and requests for PHI to the minimum necessary to accomplish the intended purpose. The provisions do not apply
to uses or disclosures made pursuant to an authorization requested by the individual by the individual.
Note: Uses and disclosures for TPO may be permitted without prior consent in an emergency.
Revised 4/3/2012 1
Name: Date of Birth:
Sex:
Male Height:
Female
Primary Care Physician: ________________________________________________
Phone Number:
Referring MD: Phone Number:
Other MD's: Name/Specialty
Pharmacy Name: Pharmacy Number:
PAST MEDICAL HISTORY: Please check all the boxes that apply
Other:
Other:
Any unusual childhood infections or illnesses?
SURGICAL HISTORY: Please list year, operation and surgeon (if known)
1.
2.
3.
4.
5.
Patient Health History
Anemia/Blood Disorders
Arthritis
Asthma
Blood Clots
Emphysema
GERD
Glaucoma
Sickle Cell Disease
Hypercholesterolemia
Hypertension
Irregular Heartbeat
Kidney Disease
Heart Disease
Cancer
Cataracts
Colitis
Diabetes
Ulcers
Current problem or reason for consultation:
Allergies
Hepatitis/Liver Disease
Pancreatitis
Sinusitis
Stroke
Thyroid
Tuberculosis
Pharmacy Address (cross streets):
City:
Zip:
12032902 Packet.indd 10 6/8/12 12:24 PM
Revised //20 1
Name: Date of Birth:
Sex:
Male
Female
Primary Care Physician: ________________________________________________
Phone Number:
Referring MD: Phone Number:
Other MD's: Name/Specialty
PAST MEDICAL HISTORY: Please check all the boxes that apply
Other:
Other:
Any unusual childhood infections or illnesses?
SURGICAL HISTORY: Please list year, operation and surgeon (if known)
1.
2.
3.
4.
5.
Patient Health History
Anemia/Blood Disorders
Arthritis
Asthma
Blood Clots
Emphysema
GERD
Glaucoma
Sickle Cell Disease
Hypercholesterolemia
Hypertension
Irregular Heartbeat
Kidney Disease
Heart Disease
Cancer
Cataracts
Colitis
Diabetes
Ulcers
Current problem or reason for consultation:
Allergies
Hepatitis/Liver Disease
Pancreatitis
Sinusitis
Stroke
Thyroid
Tuberculosis
143
12032902 Packet.indd 10 6/8/12 12:24 PM
Ethnicity / Race:
Language:
(Optional)
(Optional)
Vaccinations: Please provide date of last vaccination
Pneumonia: ________________________ Flu: ___________________ Shingles: _________________________
Revised 8/15/2011 2
ROUTINE CANCER SCREENING TESTS: List last date (if known)
SOCIAL HISTORY:
Marital Status:
Number of Children: Age/Sex of Children:
Spouse Name:
Spouse Occupation:
Patient Occupation:
Highest Level of Education:
Patient Lives With: Self
Child
Spouse Parent(s)
Sibling(s) Friend
Other
_________________
City of Residence: ___________________ Have you completed an advance directive? Yes
No
Have you completed a living will? Yes
No
Smoking History
Cigarettes
How Many Years? ____________________________
Cigars Number Per Day _____________________________
Pipe
If Quit, When? _______________________________
Alcohol History
Beer
How Many Years?_____________________________________
Wine
How Much Per Day/Week/Month? _______________________
Liquor
If Quit, When? ________________________________________
Nutritional Supplements: _________________________________________________________________________
Mammogram:
Breast Exam:
Pap Smear/Pelvic Exam:
Stool for Occult Blood:
Blood Transfusions HIV Testing
Prostate Exam/PSA:
Chest X-Ray:
Colonoscopy/Sigmoidoscopy:
Recreational Drug Use
Single Married Divorced Widowed Other
12032902 Packet.indd 11 6/8/12 12:24 PM
Revis 2
ROUTINE CANCER SCREENING TESTS: List last date (if known)
SOCIAL HISTORY:
Number of Children: Age/Sex of Children:
Spouse Name:
Spouse Occupation:
Patient Occupation:
Highest Level of Education:
Patient Lives With: Self
Child
Spouse Parent(s)
Sibling(s) Friend
Other
_________________
No
Have you completed a living will? Yes
No
Smoking History
Cigarettes
How Many Years? ____________________________
Cigars Number Per Day _____________________________
Pipe
If Quit, When? _______________________________
Alcohol History
Beer
How Many Years?_____________________________________
Wine
How Much Per Day/Week/Month? _______________________
Liquor
If Quit, When? ________________________________________
Mammogram:
Breast Exam:
Pap Smear/Pelvic Exam:
Stool for Occult Blood:
Blood Transfusions HIV Testing
Prostate Exam/PSA:
Chest X-Ray:
Colonoscopy/Sigmoidoscopy:
Recreational Drug Use
ed 3 /2014
Have you completed an advance directive? Yes
12032902 Packet.indd 11 6/8/12 12:24 PM
Name:
Revised 8/15/2011 3
ALLERGIES TO MEDICATIONS: Yes
No
NAME OF DRUG(S)/TYPE OF REACTION:
MEDICATIONS:
DOSE
(mg or
mcg)
Vaccinations: Please provide date of last vaccination
Pneumonia: ________________________ Flu: ___________________ Shingles: _________________________
FAMILY HISTORY:
Age, If Living
Sis/Bro
Sis/Bro
Father
Sis/Bro
Sis/Bro
Mother
Sis/Bro
Relative
If Deceased, Cause
Health Problems
NAME OF DRUG
HOW MANY TIMES DAILY
HOW LONG (MONTH/YEARS)
12032902 Packet.indd 12 6/8/12 12:24 PM
3
ALLERGIES TO MEDICATIONS: Yes
No
NAME OF DRUG(S)/TYPE OF REACTION:
MEDICATIONS:
DOSE
(mg or
mcg)
FAMILY HISTORY:
Age, If Living
Sis/Bro
Sis/Bro
Father
Sis/Bro
Sis/Bro
Mother
Sis/Bro
Relative
If Deceased, Cause
Health Problems
NAME OF DRUG
HOW MANY TIMES DAILY
HOW LONG (MONTH/YEARS)
12032902 Packet.indd 12 6/8/12 12:24 PM
Pharmacy Name: Pharmacy Number:
Pharmacy Address (cross streets):
City:
Zip:
Name:
Nutritional Supplements: _________________________________________________________________________
Revised 3 /2014
Revised 8/15/2011 4
For other relatives such as grandparents, aunts and uncles: Please check all boxes that apply
Anemia Diabetes
Blood Clots Heart Disease
Blood Disorders Hypertension
Cancer Stroke
Would you like to discuss this with your physician? Yes
No
REVIEW OF SYSTEMS: Please check all boxes that apply
FEVER
CHILLS
HEADACHES
BLACKOUTS
SEIZURES
DIZZINESS
HEARING
LOSS
EARACHE
LAST EYE EXAM _______________
BLEEDING
GUMS
COUGH
SPUTUM
COUGHING UP
BLOOD
WHEEZING
LAST CHEST X-RAY _____________
BRONCHITIS
LUMPS
LUMPS
NAUSEA
VOMITING
PAIN WHEN
SWALLOWING
DIFFICULTY
SWALLOWING
INDIGESTION
ABDOMEN
ABDOMINAL PAIN
CONSTIPATION
DIARRHEA
HEMORRHOIDS
BLOOD IN STOOLS
BLACK STOOLS
BREAST PAIN NIPPLE DISCHARGE
BLOATING
ULCER
GAS
HIATAL HERNIA
NECK GOITER PAIN OR STIFFNESS
CHEST
SHORTNESS OF BREATH
CHEST PAIN
PALPITATIONS
SWELLING OF FEET
ASTHMA
HOARSENESS
SORE TONGUE
NOSEBLEEDS
HIGH BLOOD
PRESSURE
HEART MURMUR
RHEUMATIC FEVER
FATIGUE
NIGHT SWEATS
TOOTHACHE
DOUBLE VISION
BLURRED VISION
CATARACTS
GENERAL
HEAD
RINGING IN EARS
SINUSITIS
POST NASAL DRIP
SORE THROAT
GLAUCOMA
WEIGHT LOSS
WEIGHT GAIN
Approximatley 10% of cancer is hereditary. If you are concerned your family may be at risk, genetic counseling may
be appropriate for you.
12032902 Packet.indd 13 6/8/12 12:24 PM
Revised 8/15/2011 4
For other relatives such as grandparents, aunts and uncles: Please check all boxes that apply
Anemia Diabetes
Blood Clots Heart Disease
Blood Disorders Hypertension
Cancer Stroke
Would you like to discuss this with your physician? Yes
No
REVIEW OF SYSTEMS: Please check all boxes that apply
FEVER
CHILLS
HEADACHES
BLACKOUTS
SEIZURES
DIZZINESS
HEARING
LOSS
EARACHE
LAST EYE EXAM _______________
BLEEDING
GUMS
COUGH
SPUTUM
COUGHING UP
BLOOD
WHEEZING
LAST CHEST X-RAY _____________
BRONCHITIS
LUMPS
LUMPS
NAUSEA
VOMITING
PAIN WHEN
SWALLOWING
DIFFICULTY
SWALLOWING
INDIGESTION
ABDOMEN
ABDOMINAL PAIN
CONSTIPATION
DIARRHEA
HEMORRHOIDS
BLOOD IN STOOLS
BLACK STOOLS
BREAST PAIN NIPPLE DISCHARGE
BLOATING
ULCER
GAS
HIATAL HERNIA
NECK GOITER PAIN OR STIFFNESS
CHEST
SHORTNESS OF BREATH
CHEST PAIN
PALPITATIONS
SWELLING OF FEET
ASTHMA
HOARSENESS
SORE TONGUE
NOSEBLEEDS
HIGH BLOOD
PRESSURE
HEART MURMUR
RHEUMATIC FEVER
FATIGUE
NIGHT SWEATS
TOOTHACHE
DOUBLE VISION
BLURRED VISION
CATARACTS
GENERAL
HEAD
RINGING IN EARS
SINUSITIS
POST NASAL DRIP
SORE THROAT
GLAUCOMA
WEIGHT LOSS
WEIGHT GAIN
Approximatley 10% of cancer is hereditary. If you are concerned your family may be at risk, genetic counseling may
be appropriate for you.
12032902 Packet.indd 13 6/8/12 12:24 PM
Name:
Revised 8/15/2011 5
CONTINUE REVIEW OF SYSTEMS: Please check all boxes that apply
BLOOD IN
URINE
# OF PREGNANCIES _________
BURNING WITH
URINATION
# OF MISCARRIAGES ________
FREQUENT
URINATION
# OF ABORTIONS ___________
DIFFICULTY
STARTING TO
URINATE
# OF CHILDREN _____________
BLADDER/
KIDNEY
INFECTIONS
GETTING UP AT
NIGHT TO
URINATE
DURATION ___________________
LAST PAP SMEAR ____________
SENSE OF FULL
BLADDER
RASH
JOINT
STIFFNESS
JOINT PAIN
EASY
BRUISING OR
BLEEDING
THYROID
PROBLEMS
ANXIETY
NERVOUSNESS
PATIENT'S SIGNATURE: _________________________________________________________________________________
PHYSICIAN'S SIGNATURE: _______________________________________________________________________________
EXCESSIVE THIRST
OR HUNGER
TRANSFUSION
REACTIONS
HEMATOLOGICAL
MEMORY LOSS
VARICOSE VEINS
ANEMIA PAST INFUSION
ITCHING
SWELLING
BACK PAIN
NEURO-
MUSCULAR
ENDOCRINE
HOT OR COLD
INTOLERANCE
PSYCHIATRIC
DEPRESSION
NIGHT CRAMPS
CHANGE IN HAIR
OR NAILS
SKIN
URINARY/GYN
LAST MENSTRUAL
PERIOD ____________________
DISCHARGE
VAGINAL INFECTIONS
CRAMPING
SPOTTING
INTERVAL ____________________
12032902 Packet.indd 14 6/8/12 12:24 PM
Revised 8/15/2011 5
CONTINUE REVIEW OF SYSTEMS: Please check all boxes that apply
BLOOD IN
URINE
# OF PREGNANCIES _________
BURNING WITH
URINATION
# OF MISCARRIAGES ________
FREQUENT
URINATION
# OF ABORTIONS ___________
DIFFICULTY
STARTING TO
URINATE
# OF CHILDREN _____________
BLADDER/
KIDNEY
INFECTIONS
GETTING UP AT
NIGHT TO
URINATE
DURATION ___________________
LAST PAP SMEAR ____________
SENSE OF FULL
BLADDER
RASH
JOINT
STIFFNESS
JOINT PAIN
EASY
BRUISING OR
BLEEDING
THYROID
PROBLEMS
ANXIETY
NERVOUSNESS
PATIENT'S SIGNATURE: _________________________________________________________________________________
PHYSICIAN'S SIGNATURE: _______________________________________________________________________________
EXCESSIVE THIRST
OR HUNGER
TRANSFUSION
REACTIONS
HEMATOLOGICAL
MEMORY LOSS
VARICOSE VEINS
ANEMIA PAST INFUSION
ITCHING
SWELLING
BACK PAIN
NEURO-
MUSCULAR
ENDOCRINE
HOT OR COLD
INTOLERANCE
PSYCHIATRIC
DEPRESSION
NIGHT CRAMPS
CHANGE IN HAIR
OR NAILS
SKIN
URINARY/GYN
LAST MENSTRUAL
PERIOD ____________________
DISCHARGE
VAGINAL INFECTIONS
CRAMPING
SPOTTING
INTERVAL ____________________
12032902 Packet.indd 14 6/8/12 12:24 PM
Name:
You’re Invited to Join the Illinois Cancer Specialists E-Mail Program
If you are interested in receiving updates from Illinois Cancer Specialists (ICS) regarding ICS news and
events, please provide your name and primary e-mail address. Submit this form during your next
appointment.
IMPORTANT: Please add ICS@usoncology.com to your safe sender list. Otherwise, e-mail may be directed
to a SPAM or junk folder.
PLEASE PRINT CLEARLY
_________________________________________________________________________________
First/Last Name E-mail Address
__________________________________________________________________________________
Illinois Cancer Specialists Notice of Disclosure for E-Mail Practices & Privacy Policy
Signature – authorizing ICS to e-mail news/updates Date
Illinois Cancer Specialists (ICS) has created this policy to demonstrate our firm commitment to your privacy and the
protection of your information.
Did you receive e-mail from ICS?
Our e-mail marketing program is permission based. If you receive e-mail from us, our records indicate that you have expressly
shared this address for the purpose of receiving information in the future ("opt-in"). We respect your time and attention by
controlling the frequency of our mailings.
If, at any time, you believe you have received unwanted, unsolicited e-mail sent via our distribution system or purporting to
be sent via our system, please forward a copy of that e-mail with your comments to ICS@usoncology.com for review.
Can you stop receiving e-mail?
Each e-mail sent contains an easy, automated way for you to cease receiving e-mail from the lists to which you are
subscribed, or to change your expressed interests. If you wish to do this, simply follow the instructions to unsubscribe
How we protect your privacy
provided
in every e-mail.
We use security measures such as encryption to protect against the loss, misuse and alteration of data used by our system.
Sharing and Usage of Account Information
We will never share, sell, or rent your personal account information or subscriber data with anyone without your advance
permission or unless ordered by a court of law. Information submitted to us is only available to employees managing this
information for purposes of contacting you or sending you e-mails based on your request for information and to contracted
service providers for purposes of providing services relating to our communications with you.
Privacy Policy Changes
If this privacy policy changes in the future, all account holders will be notified of the change at least ten (10) days before it
occurs and have the option to terminate his or her account and thus have their data removed from the system. This policy
was created in August 2011.
12032902 Packet.indd 15 6/8/12 12:24 PM
You’re Invited to Join the Illinois Cancer Specialists E-Mail Program
If you are interested in receiving updates from Illinois Cancer Specialists (ICS) regarding ICS news and
events, please provide your name and primary e-mail address. Submit this form during your next
appointment.
IMPORTANT: Please add ICS@usoncology.com to your safe sender list. Otherwise, e-mail may be directed
to a SPAM or junk folder.
PLEASE PRINT CLEARLY
_________________________________________________________________________________
First/Last Name E-mail Address
__________________________________________________________________________________
Illinois Cancer Specialists Notice of Disclosure for E-Mail Practices & Privacy Policy
Signature – authorizing ICS to e-mail news/updates Date
Illinois Cancer Specialists (ICS) has created this policy to demonstrate our firm commitment to your privacy and the
protection of your information.
Did you receive e-mail from ICS?
Our e-mail marketing program is permission based. If you receive e-mail from us, our records indicate that you have expressly
shared this address for the purpose of receiving information in the future ("opt-in"). We respect your time and attention by
controlling the frequency of our mailings.
If, at any time, you believe you have received unwanted, unsolicited e-mail sent via our distribution system or purporting to
be sent via our system, please forward a copy of that e-mail with your comments to ICS@usoncology.com
for review.
Can you stop receiving e-mail?
Each e-mail sent contains an easy, automated way for you to cease receiving e-mail from the lists to which you are
subscribed, or to change your expressed interests. If you wish to do this, simply follow the instructions to unsubscribe
How we protect your privacy
provided
in every e-mail.
We use security measures such as encryption to protect against the loss, misuse and alteration of data used by our system.
Sharing and Usage of Account Information
We will never share, sell, or rent your personal account information or subscriber data with anyone without your advance
permission or unless ordered by a court of law. Information submitted to us is only available to employees managing this
information for purposes of contacting you or sending you e-mails based on your request for information and to contracted
service providers for purposes of providing services relating to our communications with you.
Privacy Policy Changes
If this privacy policy changes in the future, all account holders will be notified of the change at least ten (10) days before it
occurs and have the option to terminate his or her account and thus have their data removed from the system. This policy
was created in August 2011.
12032902 Packet.indd 15 6/8/12 12:24 PM
Notice of Disclosure for E-Mail Practices & Privacy Policy
Illinois Cancer Specialists (ICS) has created this privacy policy to demonstrate our firm
commitment to your privacy and the protection of your information.
Why did you receive e-mail from ICS?
Our e-mail marketing program is permission based. If you receive an e-mail from us, our records
indicate that you have expressly shared this address for the purpose of receiving information in
the future ("opt-in"). We respect your time and attention by controlling the frequency of our
mailings.
If you believe you have received unwanted, unsolicited e-mail sent via our distribution system or
purporting to be sent via our system, please forward a copy of that e-mail with your comments to
How can you stop receiving e-mail?
Each e-mail sent contains an easy, automated way for you to cease receiving e-mail from the lists to
which you are subscribed, or to change your expressed interests. If you wish to do this, simply follow
the instructions to
unsubscribe
How we protect your privacy
provided in every e-mail.
We use security measures, such as encryption, to protect against the loss, misuse and
alteration of data used by our system.
Sharing and Usage of Account Information
We will never share, sell, or rent your personal account information or subscriber data with anyone
without your advance permission or unless ordered by a court of law. Information submitted to us is
only available to employees managing this information for purposes of contacting you or sending you
e-mails based on your request for information and to contracted service providers for purposes of
providing services relating to our communications with you.
Privacy Policy Changes
If this privacy policy changes in the future, all account holders will be notified of the change at least ten
(10) days before it occurs and have the option to terminate his or her account and thus have their data
removed from the system. This policy was created in August 2011.
12032902 Packet.indd 16 6/8/12 12:24 PM
Notice of Disclosure for E-Mail Practices & Privacy Policy
Illinois Cancer Specialists (ICS) has created this privacy policy to demonstrate our firm
commitment to your privacy and the protection of your information.
Why did you receive e-mail from ICS?
Our e-mail marketing program is permission based. If you receive an e-mail from us, our records
indicate that you have expressly shared this address for the purpose of receiving information in
the future ("opt-in"). We respect your time and attention by controlling the frequency of our
mailings.
If you believe you have received unwanted, unsolicited e-mail sent via our distribution system or
purporting to be sent via our system, please forward a copy of that e-mail with your comments to
for review.
How can you stop receiving e-mail?
Each e-mail sent contains an easy, automated way for you to cease receiving e-mail from the lists to
which you are subscribed, or to change your expressed interests. If you wish to do this, simply follow
the instructions to
unsubscribe
How we protect your privacy
provided in every e-mail.
We use security measures, such as encryption, to protect against the loss, misuse and
alteration of data used by our system.
Sharing and Usage of Account Information
We will never share, sell, or rent your personal account information or subscriber data with anyone
without your advance permission or unless ordered by a court of law. Information submitted to us is
only available to employees managing this information for purposes of contacting you or sending you
e-mails based on your request for information and to contracted service providers for purposes of
providing services relating to our communications with you.
Privacy Policy Changes
If this privacy policy changes in the future, all account holders will be notified of the change at least ten
(10) days before it occurs and have the option to terminate his or her account and thus have their data
removed from the system. This policy was created in August 2011.
12032902 Packet.indd 16 6/8/12 12:24 PM
1.800.ACS.2345
www.cancer.org
Hope.Progress.Answers
800-782-7716(T) / 312-279-7237(F)
Illinois Cancer Specialists: Please check your hospital
Northwest Community Hospital: 0511111804
Advocate Lutheran General Hospital: 1-CN9NRC
Alexian Brothers Medical Center: 1-10B7WWE
Resurrection Hospital: 1424210034
Today’s Date _______/________/________
Please fill out this form completely so that the American Cancer Society can better serve you. Thank you.
Name:__________________________________________________________________
Phone: _____________________ E-Mail: _____________________________________
Can we leave a message? (Y/N)_______________
Address: ___________________________________________________________________
City: ___________________________________________State: _______Zip: ______________
Gender (Male/Female) : _______ Race: _____________ Date of Diagnosis: _____/_____/_______
Type of Cancer: __________________________________________________________________
Treatment (Chemotherapy/Radiation): ____________________________
Insurance:
Private
Medicare
Medicaid
Uninsured
All information you provide will remain confidential. All information and services are free. I would like
information on the following American Cancer Society services (check all that apply):
Patient Signature:
____________________________________________________________________________________________
The American Cancer Society cares about your privacy and protects how we use your information. The information on this form will be used by the
society to better serve you and your community. We may also use your information to invite you to participate in an upcoming event in your area. To
view the Society’s complete privacy policy, or if you have questions about the Society’s privacy standards, please contact us at 800-227-2345. By signing
this form, you agree and give permission to the Society to use and share your information internally. The American Cancer Society is available day or
night, for information and support, by calling 1-800-227-2345
PLEASE FAX THE COMPLETED FORM TO: 1-312-279-7237
□ Information about my my cancer
□ Understanding Treatment Options
□ Transportation Assistance
□ Skin Care Session with Licensed Cosmetologist
□ Cancer Help Kit (Personal Health Manager)
□ Resources/Guidance (i.e. financial, lodging, etc.)
□ Nutrition during treatment
□
Clinical Trials
□ Insurance
□ Support Groups
□ Wigs/Turbans/Hats
□ One-on-one contact with a survivor
of the same cancer
12032902 Packet.indd 17 6/8/12 12:24 PM
1.800.ACS.2345
www.cancer.org
Today’s Date _______/________/________
Please fill out this form completely so that the American Cancer Society can better serve you. Thank you.
Name:__________________________________________________________________
Phone: _____________________ E-Mail: _____________________________________
Can we leave a message? (Y/N)_______________
Address: ___________________________________________________________________
City: ___________________________________________State: _______Zip: ______________
Gender (Male/Female) : _______ Race: _____________ Date of Diagnosis: _____/_____/_______
Type of Cancer: __________________________________________________________________
Treatment (Chemotherapy/Radiation): ____________________________
Insurance:
Private
Medicare
Medicaid
Uninsured
All information you provide will remain confidential. All information and services are free. I would like
information on the following American Cancer Society services (check all that apply):
Patient Signature:
____________________________________________________________________________________________
The American Cancer Society cares about your privacy and protects how we use your information. The information on this form will be used by the
society to better serve you and your community. We may also use your information to invite you to participate in an upcoming event in your area. To
view the Society’s complete privacy policy, or if you have questions about the Society’s privacy standards, please contact us at 800-227-2345. By signing
this form, you agree and give permission to the Society to use and share your information internally. The American Cancer Society is available day or
night, for information and support, by calling 1-800-227-2345
PLEASE FAX THE COMPLETED FORM TO: 1-312-279-7237
□ Information about my my cancer
□ Understanding Treatment Options
□ Transportation Assistance
□ Skin Care Session with Licensed Cosmetologist
□ Cancer Help Kit (Personal Health Manager)
□ Resources/Guidance (i.e. financial, lodging, etc.)
□ Nutrition during treatment
□
Clinical Trials
□ Insurance
□ Support Groups
□ Wigs/Turbans/Hats
□ One-on-one contact with a survivor
of the same cancer
12032902 Packet.indd 17 6/8/12 12:24 PM
Illinois Cancer Specialists: Please check your hospital
Northwest Community Hospital: 0511111804
Advocate Lutheran General Hospital: 1-CN9NRC
Alexian Brothers Medical Center: 1-10B7WWE
Resurrection Hospital: 1424210034
Advocate Good Samaritan, Downers Grove - 1468195034
Advocate Sherman Hospital, Elgin - 1078705034
Presence St. Joseph Hospital, Elgin - 1078705034
Centegra Northern Illinois Medical Center, McHenry - 1-T628UT
Centegra Memorial Medical Center, Woodstock - 1-E3XBGZ
St Alexis Medical Center, Homan Estates - 1-MWBLVL
Adventist Hinsdale Hospital - 1-HYQUN7
Adventist Bolingbrook Hospital - 1-1VFFTVT
Enroll Today!
Illinois Cancer Specialists is pleased to oer you this
valuable online service. Simply tell our sta you’re
interested, and we’ll help you get started.
My Care Plus:
Get secure, convenient access to information about
your diagnosis, medications, lab results and more.
MyCarePlusOnline.com
12041704-Flyer-ICS.indd 1 4/20/12 2:36 PM12032902 Packet.indd 18 6/8/12 12:24 PM
Enroll Today!
Illinois Cancer Specialists is pleased to oer you this
valuable online service. Simply tell our sta you’re
interested, and we’ll help you get started.
My Care Plus:
Get secure, convenient access to information about
your diagnosis, medications, lab results and more.
MyCarePlusOnline.com
12041704-Flyer-ICS.indd 1 4/20/12 2:36 PM12032902 Packet.indd 18 6/8/12 12:24 PM
Introducing a New Convenient Way to Connect: Online!
The Message Center is a new feature that allows you to securely
communicate with your practice’s care team through the
online portal, My Care Plus
SM
.
You may use the Message Center for non-urgent
*
topics like:
• Scheduling appointments and cancellations
• Diagnostics preparation
• Questions about lab results
• Non-urgent medication questions
To use the Message Center, enroll in My Care Plus by completing
and submitting the consent form at the front desk.
* For urgent matters, contact your physician’s office or call 911.
www.MyCarePlusOnline.com
MY CARE PLUS
To send and receive messages through the Message Center:
1. Log in to My Care Plus www.MyCarePlusOnline.com
2. Click the Message Center link
To send a message:
3. Click Compose Message from the menu
4. Select your doctor, enter your subject and message, and click Send
To view and reply to your received messages:
• Click the Inbox link
• Click anywhere on the message to open and read
•
Use the Reply Message box at the bottom to enter your message,
and click Reply
If you have questions regarding enrollment in My Care Plus,
please contact your practice.
If you need assistance with the Message Center, please contact My Care Plus
Support by email at [email protected] or call 855.887.6788.
www.MyCarePlusOnline.com
My Care Plus Instructions
• Your care team will make every attempt to respond to your messages quickly,
but some responses may take up to 48 hours.
• A sta member, such as a nurse or administrative sta, may respond to your
message on behalf of your doctor.
• Do not use the Message Center for emergencies.
2
1
3
4
The US Oncology Network is supported by McKesson Specialty Health. © 2014 McKesson Specialty Health. All rights reserved.
www.MyCarePlusOnline.com
