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.

By completing this registration form, I agree to participate with the INTERLINK CancerCARE program.


*Required Fields

Patient Information
Name: *
Date of Birth: *
Gender:
Home Phone:
Cell Phone:
Other Phone:
Email: *
Preferred contact method:
Best time to contact you:
Address: *
Please list anyone we can speak to on your behalf:
Insurance (This information can be found on your insurance card)
Health Plan:
Is this your primary insurance?
Member ID number:
Employer name of subscriber: *
Are you the subscriber or a dependent?
If you are the dependent, who is the subscriber and what is their date of birth?
Do you have any secondary insurance?
Diagnosis
What is your cancer diagnosis?
What date were you diagnosed?
Have you had surgery?
Date Started:
Date Completed:
Have you had radiation therapy?
Date Started:
Date Completed:
Have you had chemotherapy?
Date Started:
Date Completed:
Provider Names & Contact Information (If you do not have this infromation, we will contact you to follow up)
Primary Care Physician (Name & Address):
Surgeon (Name & Address):
Medical Oncologist (Name & Address):
Radiation Oncologist (Name & Address):
Hospital (Name & Address):
Other (Name & Address): 
Additional Information Needed to Better Advocate for You
Do you live alone or do you have someone in the home who can help if needed?
Do you have adequate family/friend support system available to you?
Are you currently working?  What type of work? (e.g. desk job vs. physically demanding work)
Is it possible you may need help getting around your home?
 

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.