New patient registration form

This is the Cancer Center Sarasota-Manatee online new patient registration form. It is a SSL secure form that ensures that your data is safe whilst you complete the it. Upon submission the form data is encrypted and then securely transmitted to the secure HIPAA compliant data storage servers. The encrypted form data remains on the HIPAA FORMS Service database and can not be tampered with or changed by anyone.
Please enter your data into the online form. When complete, please click the “Submit” button.

Primary Insurance Information

Secondary Insurance (if applicable):

Authorization and Agreement – I request that benefits be paid by my insurer or health plan (including Medicare) directly to Cancer Center of Sarasota. I understand that I will be responsible for any outstanding or unpaid balance on my bill. I certify that the information I have reported with regard to my insurance is correct. I authorized the release of medical or other necessary information for this or any related claim to my insurance carrier, or in the case of Medicare Part B benefits, to the Social Security Administration and Health Care Financing Administration. I permit a copy of this authorization to be used in lace of the original. I authorize the release of my medical records as requested orally or in written form by my physician or me. I have read and consent to the authorization and assignment stated above.

Financial Agreement: I understand that I am responsible for the payment of any sums not covered by my health insurance. I further understand that if I don’t carry health insurance, I am responsible for payment of the full amount. I understand that I am responsible for the payment of this account and hereby assume and guarantee payment of expenses incurred by myself or my descendents. Should legal action be required to secure payment of this account I agree to a reasonable collection expense, all court costs and reasonable attorney’s fees incurred thereby.

Please type your name into the box.
You must agree to the HIPPA FORMS Service Privacy Statement below, by clicking or tapping in the check box, and sign in the large grey box using your mouse, finger or stylus as appropriate, before you can submit this form.

Sarasota: 3830 Bee Ridge Road, Suite 301, Sarasota, FL 34233 | (941)923.1872
Bradenton: 4351 Cortez Road, Suite 100, Bradenton, FL 34210 | (941)755.0606
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