CancerCARE Homepage » Members » Registration » Step 1: Intake

Step 1: Intake

Members

If you or your family member has been diagnosed with cancer and your health plan offers the CancerCARE Program, please complete the fields below with all known information. Once submitted, a confirmation email will be sent to you to confirm the first step to a successful registration.

Patient Information
Name
Date of Birth:
Gender:
Home Phone:
Cell Phone:
Other Phone:
Email
Preferred contact Method:
If Other?:
Address:
Who do you give us permission to speak with on your behalf?:
Would you like to participate in the CancerCARE program?:
May we request medical records on your behalf?:
If no, please indicate why:
Insurance
Health Plan:
Member ID number:
Employer Name:
Are you the primary card holder?:
If not, who is the primary card holder?:
and their date of birth?:
Secondary Insurance?:
Diagnosis
What is your cancer diagnosis?:
Has your doctor told you what stage your disease is?:
If so, please indicate:
Date of diagnosis:
Have you started your treatment or had surgery yet?:
If so, when?:
What kind of treatment/surgery?:
Are you receiving treatment or planning upcoming surgery?:
Are you in remission?:
Providers
Please list the name, address and phone numbers of any physicians you are currently seeing (eg) Primary care Physician, Oncologist, Radiation Oncologist, Surgeon:
Hospitals
Please list the name, address and phone numbers of any hospitals you are currently using:
We would like to ask a few questions that will help us know and understand your needs, so we may better help you:
How did you know to contact CancerCARE?:
Do you live alone?:
If no, with who?:
Do you live in a single level home?:
Do you have adequate family/friend support available to you?:
Are you currently working?:
What type of work do you do?:

By completing this form you are authorizing a CancerCARE specialist to contact you. This information is confidential and meets HIPAA guidelines. To review our Privacy Policy please refer to Notice of Privacy Practices.