Authorization for Cancer Treatment and Related Services

Patient Information

Name: _________________________ Date of Birth: _____________ Medical Record #: ______________ Date: _____________________

Treatment Authorization

I, _________________________________, hereby authorize Dr. _________________________ and associates to administer cancer treatment, which may include:

• Chemotherapy
• Immunotherapy
• Targeted therapy
• Hormone therapy
• Radiation therapy
• Other related cancer treatments as deemed medically necessary

Understanding of Treatment

I acknowledge that:

1. The nature and purpose of the treatment(s) have been explained to me
2. Potential benefits and risks have been discussed
3. Alternative treatment options have been presented
4. No guarantees have been made regarding treatment outcomes

Financial Responsibility

I understand that:

• I am responsible for any charges not covered by my insurance
• Prior authorization may be required for certain treatments
• Laboratory and imaging studies may be billed separately

Consent for Information Release

I authorize the release of medical information to:

• Insurance companies for billing purposes
• Other healthcare providers involved in my care
• Designated family members (specify below):

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Emergency Contact

Name: _________________________ Relationship: ____________ Phone: ________________________

Signatures

Patient Signature: __________________ Date: ____________ Witness Signature: __________________ Date: ____________ Physician Signature: ________________ Date: ____________

This authorization remains valid for one year unless revoked in writing.