Brain Tumor Second Opinion Form - Culicchia Neurological Clinic

MEDICAL SECOND OPINION BRAIN TUMOR AND NEURO-ONCOLOGY REQUEST FORM

I am requesting Culicchia Neurological Clinic to provide a remote second opinion of my condition.
Agreement*
I understand that this second opinion is based solely on the materials provided to Culicchia Neurological Clinic, without a physical exam. As such, there are risks and limitations of any medical opinion provided. I agree to provide copies of my medical records and any other relevant diagnostic reports or studies. I also understand as the patient requesting the remote second opinion, only I will receive a copy of the assessment and recommendation and it is my responsibility to forward the report to my treating physician(s) or other providers. I also understand that I will be provided with a second opinion only and that this request will create no physician-patient relationship with any physician at Culicchia Neurological Clinic.
- I Agree

Please check all that apply:*
I have:
- a brain tumor.
- cancer that has spread to my brain and/or other parts of my nervous system
- cancer with neurologic symptoms that may be due to the cancer or the treatment of my cancer
Please provide a short description of your history relating to this diagnosis and the question(s) to be answered by this second opinion:*
Patient First Name*
Patient Last Name*
Date of Birth*
MM slash DD slash YYYY
Height*
Weight*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number*
Email*
Agreement
Statement of Financial Responsibility - I understand that I am responsible for payment to Culicchia Neurological Clinic, LLC for this second opinion. I understand that I am ultimately responsible for all medical expenses incurred and agreed to pay all amounts. HIPAA Regulations - I agree that Culicchia Neurological Clinic may request and use my prescription medication history from other healthcare providers or third-party pharmacy benefit payors for purposes of clarification of medical history. The following signature acknowledges that I have received notification of my privacy rights concerning the use and disclosure of protected health information as defined by the privacy regulations.
Signature*
I agree.
Today's Date
MM slash DD slash YYYY

MEDICAL SECOND OPINION BRAIN TUMOR AND NEURO-ONCOLOGY REQUEST FORM