Atlas Radiation Medicine (716) 555-0100 3910 N. Buffalo Road, Orchard Park, NY
Before Your First Visit

New Patient Forms

Complete your intake paperwork online at your own pace. Your information is transmitted securely and reviewed by our care team before your appointment.

1
Patient IntakeDemographics & referring provider
2
InsuranceCoverage & authorization
3
Consent & SubmitHIPAA & treatment authorization

Patient Information

Please fill in your personal details and let us know who referred you. Fields marked * are required.

Personal Details
Please enter your first name.
Please enter your last name.
Please enter your date of birth.
Please select an option.
Please enter a valid phone number.
Please enter a valid email address.
Please enter your address.
Emergency Contact
Please enter an emergency contact name.
Please select a relationship.
Please enter a phone number.
Referring Provider

Insurance Information

We accept most major insurance plans. If you are uninsured or self-pay, select that option below and our team will work with you on a payment plan.

Primary Insurance
Please select an insurance type.
Secondary Insurance (if applicable)
Prior Authorization

Consent & Authorization

Please read and acknowledge the following agreements. Your electronic signature below is legally binding.

Consent to Treatment

I voluntarily consent to evaluation, diagnostic procedures, and treatment by Atlas Radiation Medicine (Atlas Rad-Onc, LLC dba Atlas Radiation Medicine) and the physicians and clinical staff associated with this practice.

I understand that radiation therapy involves the use of ionizing radiation to treat disease, and that the nature, purposes, risks, and alternatives of any recommended treatment will be explained to me by Dr. Hallock before treatment begins. I acknowledge that medicine is not an exact science and that no guarantee has been made to me about the outcome of any treatment.

I understand that I have the right to refuse or withdraw consent for treatment at any time, and that such refusal will be respected.

You must agree to the Consent to Treatment to continue.
HIPAA Privacy Authorization

I acknowledge receipt of the Notice of Privacy Practices of Atlas Radiation Medicine, which describes how my protected health information (PHI) may be used and disclosed. I understand that I have certain rights regarding my health information as outlined in that notice.

I authorize Atlas Radiation Medicine to use and disclose my PHI for the purposes of treatment, payment, and healthcare operations. I also authorize the release of records and information to my referring physician, insurance carriers, and other treating providers as necessary to coordinate my care.

I understand that I may revoke this authorization in writing at any time, except to the extent that action has already been taken based upon this authorization.

You must acknowledge the HIPAA Privacy Authorization to continue.
Financial Responsibility

I understand that I am financially responsible for all charges incurred for services rendered by Atlas Radiation Medicine, regardless of insurance coverage or third-party liability. I authorize my insurance carrier to pay benefits directly to Atlas Radiation Medicine.

I agree to pay any deductibles, co-payments, co-insurance, or non-covered charges in a timely manner. I understand that if my account becomes overdue, it may be referred to a collection agency.

You must accept financial responsibility to continue.
Electronic Signature
By typing your name you confirm that all information provided is accurate and complete to the best of your knowledge, and that you agree to all consents above. Please type your full name as your electronic signature.

Your information is transmitted securely using 256-bit encryption. We will never sell or share your personal health information. Submissions are received directly by our care team and reviewed before your appointment.

Forms Received

Thank you — your new patient information has been securely submitted to our care team. You will receive a confirmation email shortly, and a member of our team will reach out within one business day to confirm your appointment details.

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