Patient Form

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  • Primary Insurance Information

  • Secondary Insurance Information

  • If there are any medical forms that need to be filled out by Merced Comprehensive Cancer Center staff there will be a charge of $20.00-$50.00 depending on the type of medical forms
  • There will be a $25.00 charge for all No Show and same day cancelation appointments: We require a 24 hour notice for all cancelation
  • I have received a copy of Comprehensive Cancer Center’s Notice of Privacy Practices
  • This feature is used as another source to contact patients and notify them of upcoming events. No medical information will be disclosed.
  • (I give Merced Cancer Center permission to email me at the above email address and I understand no medical history/information will be disclosed.)
  • I hereby authorize Merced Comprehensive Cancer Center to furnish my insurance company with all information that they might request concerning my illness or injury. I hereby assign all Payments to Merced Comprehensive Cancer Center to which I am entitled and responsible Merced Comprehensive Cancer Center for all charges covered by this assignment. All charges not covered by this assignment and all charges not covered by the insurance company will be my responsibility.
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  • Please indicate if patient is in a nursing facility or rehabilitation facility

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  • (All patients coming to be seen at our office will need prior Authorization prior to any visits from the Facility which the patient is staying in.)