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Blank Florida Hospital PDF Form

The Florida Hospital form is an essential document used for new patient intake in various oncology specialties. This form collects vital information about the patient, including personal details, insurance information, and the reason for the appointment. Completing this form accurately helps ensure timely scheduling and efficient processing of your referral.

To begin your journey towards receiving care, please fill out the form by clicking the button below.

Article Guide

The Florida Hospital form is a vital document designed to streamline the patient intake process for those seeking specialized cancer care. Upon receiving a referral request, the hospital aims to schedule appointments within a prompt 3-5 day timeframe, ensuring timely access to essential medical services. The form collects crucial patient information, including personal details such as name, address, and date of birth, as well as insurance information for both primary and secondary providers. Patients are also asked to indicate the reason for their appointment, whether it’s a new diagnosis, disease progression, or a second opinion. This helps the medical team prioritize urgent cases effectively. Additionally, the form requires the referring physician's information and prompts the submission of necessary medical records, such as history and physical reports, imaging results, and laboratory tests. By completing and submitting this form, patients can facilitate their journey toward receiving the specialized care they need, while the hospital ensures that all relevant information is gathered for a smooth and efficient appointment process.

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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 [email protected] 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

➤ PDF File

Form Specifications

Fact Name	Details
Form Title	New Patient Intake Form V1.1
Appointment Scheduling	Patients are typically seen within 3-5 days from the receipt of the referral request.
Primary Care Physicians	Referring and primary care physicians' contact information is required on the form.
Insurance Information	Details about primary and secondary insurance, including company names and policy numbers, must be provided.
Urgent Appointments	The form includes a section to indicate if an urgent appointment is needed.
Required Documents	Specific documents must be sent to expedite the referral, including history, physical, and lab reports.
Contact Information	Patients can reach out with questions at (386) 231-4050.
Email Submission	The completed form should be emailed to [email protected].
Governing Law	This form is governed by Florida state law, particularly concerning patient privacy and medical records.
Chart Management	Details regarding chart creation and management are included for internal processing.

Florida Hospital: Usage Guidelines

Completing the Florida Hospital form is an important step in ensuring that your appointment and medical needs are addressed promptly. This form collects essential information about the patient, their insurance, and the reason for the appointment. Follow the steps below to accurately fill out the form.

Begin with the section labeled Patient Information. Fill in your first name, last name, and date of birth.
Provide your complete address, including city, state, and zip code.
List your primary phone number and any secondary phone numbers, specifying whether they are home, cell, or work.
Enter your Social Security number.
Select your gender and race from the provided options.
Move on to the Primary Insurance section. Write down the name and phone number of your insurance company.
Fill in the subscriber’s name, policy number, group number, and the subscriber’s date of birth and Social Security number.
If applicable, indicate whether you have secondary insurance by completing the corresponding fields with the same information as above.
Answer the question regarding whether an urgent appointment is needed and provide the reason for the appointment.
In the Referring Physician section, include the name and phone number of your referring physician and primary care physician.
Use the comments section to add any additional notes or information you feel is necessary.
Once completed, email the form to [email protected] or fax it to (386) 231-4001.

Your Questions, Answered

What is the Florida Hospital form used for?

The Florida Hospital form serves as a New Patient Intake Form for individuals seeking cancer care. It collects essential patient information, including personal details, insurance information, and medical history. This information is crucial for scheduling appointments with specialists and ensuring that the patient receives timely care, typically within 3-5 days of the referral request.

How do I fill out the Florida Hospital form?

To complete the Florida Hospital form, start by providing your personal information, such as your first and last name, address, and date of birth. Next, include your primary and secondary phone numbers. Then, fill in your insurance details, including the insurance company name, subscriber's name, policy number, and group number. Additionally, indicate the reason for your appointment and provide any relevant medical history or documents as requested. Once completed, email the form to the designated address or fax it as instructed.

What documents are required from the referring physician's office?

To expedite the referral process, the referring physician's office must provide several documents. These include demographics, history and physical reports, operative reports, CT scans, ultrasounds, mammograms, recent lab results, insurance information, pathology reports, PET scans, MRIs, bone scans, and office notes. Submitting these documents along with the intake form helps ensure a smooth transition into care.

How can I schedule an appointment with a specialist?

To schedule an appointment with a specialist at Florida Hospital, complete the New Patient Intake Form and indicate your preferred physician from the options available, such as Dr. Seema Harichand-Herdt for Hematology Oncology or Dr. Michael Kelley for Medical Oncology. Once the form is submitted, the scheduling team will contact you to confirm the appointment date and time.

What if I need an urgent appointment?

If you require an urgent appointment, it is important to indicate this on the Florida Hospital form. The form includes a section to specify if you need to be seen urgently, such as for a new diagnosis or disease progression. This information allows the scheduling team to prioritize your case and facilitate a quicker appointment, ideally within 24-48 hours from receipt of the referral.

Where can I download a blank version of the Florida Hospital form?

A blank version of the Florida Hospital New Patient Intake Form can be downloaded from the official website at www.floridahospitalmemorial.org/cancer. This allows patients and referring physicians to access the form easily and ensures that all necessary information is captured for a successful referral process.

Common mistakes

Incomplete Patient Information: Many individuals neglect to fill out all required fields, such as the date of birth or social security number. This can lead to delays in processing the appointment.
Incorrect Insurance Details: Providing inaccurate insurance information, including the policy number or subscriber's name, can result in complications with billing and coverage verification.
Missing Referring Physician Information: Failing to include the name and contact details of the referring physician can hinder communication and delay the scheduling of appointments.
Not Indicating Urgency: Some patients forget to mark whether their appointment is urgent. This oversight can affect the prioritization of their case and the speed of care they receive.
Omitting Medical History: It is crucial to provide a complete medical history. Missing details about previous diagnoses or treatments can lead to inappropriate care decisions.
Failure to Submit Required Documents: Not sending the necessary records, such as lab results or imaging reports, can delay the appointment process. These documents are essential for the medical team to prepare adequately.

Documents used along the form

When navigating the healthcare system, especially in oncology, several forms and documents play a crucial role in ensuring a smooth process. These documents help facilitate communication between patients, healthcare providers, and insurance companies. Below is a list of commonly used forms that accompany the Florida Hospital form, each serving a specific purpose in the patient care journey.

Patient Demographics Form: This document collects essential information about the patient, including contact details, insurance information, and emergency contacts. It ensures that healthcare providers have accurate and up-to-date information for effective communication.
History and Physical (H&P) Report: This report provides a comprehensive overview of the patient's medical history and current physical condition. It is typically completed by the referring physician and is vital for the oncology team to understand the patient's background and health status.
Operative Report: After any surgical procedure, an operative report is generated. It details the surgical process, findings, and any complications that occurred, providing critical information for ongoing care.
Radiology Reports: These include reports from imaging studies such as CT scans, MRIs, and ultrasounds. They help in diagnosing conditions and planning treatment by offering visual insights into the patient's health.
Lab Results: Recent laboratory tests are essential for assessing the patient's health and guiding treatment decisions. This document includes blood work and other pertinent lab results that may impact the patient's care.
Insurance Information Form: This form details the patient's insurance coverage, including policy numbers and subscriber information. It is crucial for verifying coverage and ensuring that claims are processed correctly.
Pathology Report: Generated after tissue samples are analyzed, this report provides critical information regarding any cancer diagnosis, including the type and stage of cancer, which is vital for treatment planning.
Referral Form: This document initiates the patient's transfer to the oncology department from their primary care physician. It includes the reason for the referral and any pertinent medical history, ensuring continuity of care.
Patient Consent Forms: These forms are necessary for obtaining the patient's consent for treatment, procedures, and sharing medical information. They ensure that patients are informed and agree to the proposed care plan.

Understanding these documents can empower patients and their families as they navigate the complexities of oncology care. Each form plays a vital role in ensuring that the patient's journey is as seamless and informed as possible. Always remember to ask questions if any part of the process is unclear; clear communication is key to effective healthcare.

Similar forms

The Florida Hospital form is an essential document for new patient intake, particularly in oncology settings. Several other forms serve similar purposes in healthcare environments. Here’s a list of eight documents that share similarities with the Florida Hospital form:

Patient Registration Form: This document collects essential patient information, such as demographics and insurance details, similar to the Florida Hospital form.
New Patient Questionnaire: Like the Florida Hospital form, this questionnaire gathers medical history and current health concerns to prepare for the patient's first appointment.
Referral Form: A referral form is used to provide details about a patient's need for specialized care, mirroring the referral request process in the Florida Hospital form.
Insurance Verification Form: This form is utilized to confirm a patient's insurance coverage, paralleling the insurance information section found in the Florida Hospital form.
Medical History Form: Similar to the Florida Hospital form, this document collects comprehensive health information to inform the care team about the patient's background.
Appointment Confirmation Form: This form serves to confirm the details of a scheduled appointment, much like the appointment scheduling aspect of the Florida Hospital form.
Consent for Treatment Form: This document ensures that patients understand and agree to the proposed treatments, akin to the acknowledgment of care in the Florida Hospital form.
Release of Information Form: This form allows healthcare providers to share patient information with other entities, similar to the records sharing outlined in the Florida Hospital form.

Each of these documents plays a vital role in streamlining patient care and ensuring that all necessary information is collected efficiently.

Dos and Don'ts

When filling out the Florida Hospital form, it is essential to ensure accuracy and completeness. Here are seven things to keep in mind:

Do double-check all personal information, including name, address, and date of birth, for accuracy.
Do provide both primary and secondary insurance information, including policy numbers and subscriber details.
Do indicate if the appointment is urgent, and clearly state the reason for the visit.
Do ensure that all required documents from the referring physician are included with the form.
Don't leave any sections blank. If a question does not apply, indicate that clearly.
Don't forget to sign and date the form before submitting it.
Don't submit the form without reviewing it for any errors or missing information.

By following these guidelines, you can help streamline the appointment scheduling process and ensure that your information is processed efficiently.

Misconceptions

Understanding the Florida Hospital form is crucial for ensuring a smooth patient intake process. However, several misconceptions often arise. Here are seven common misunderstandings:

The form is only for new patients. Many believe this form is exclusively for new patients. In reality, it can also be used for existing patients who require updated information or a new referral.
Urgent appointments are guaranteed. Some people think that marking "urgent" on the form guarantees an immediate appointment. While it prioritizes the request, actual appointment availability still depends on the schedule of the doctors.
All required documents must be sent at once. There is a misconception that all necessary documents must accompany the form upon submission. In fact, documents can be sent separately, but timely submission is crucial for a quicker appointment.
Insurance information is optional. Many assume that providing insurance details is not essential. However, accurate insurance information is vital for processing referrals and ensuring coverage for services.
Patients can schedule their own appointments. Some believe they can directly schedule their appointments without going through the referral process. This is not the case; appointments must be arranged through the referring physician.
The form can be submitted via any email. There is a common belief that the form can be sent to any email address. It must be sent specifically to [email protected] to ensure it reaches the right department.
Follow-up is unnecessary after submission. Many think that once the form is submitted, no further action is required. In fact, following up is advisable to confirm receipt and check on appointment status.

Addressing these misconceptions can help streamline the patient intake process and ensure that all necessary steps are taken for timely care.

Key takeaways

When filling out and using the Florida Hospital form, consider the following key takeaways:

Timely Submission: Ensure the form is completed and submitted as soon as possible to facilitate an appointment within the 3-5 day timeframe.
Accurate Information: Provide accurate patient information, including full name, date of birth, and contact details, to avoid delays.
Insurance Details: Include both primary and secondary insurance information. This includes the insurance company name, policy number, and subscriber details.
Referral Documentation: Attach required documents from the referring physician’s office, such as history and physical, operative reports, and recent lab results.
Urgent Appointments: Indicate if the appointment is urgent and specify the reason for the visit to prioritize scheduling.
Contact Information: Use the provided email and phone number for any questions or to submit the completed form.
Follow-Up: After submission, ensure that all necessary records have been received and confirm the appointment details.
Patient Notification: The patient should be informed about their appointment date and time, as well as any necessary preparations.

By keeping these points in mind, the process of filling out and using the Florida Hospital form can be streamlined and efficient.