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Refer a Patient

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Refer a Patient

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Form Completed By *

First

Middle

Last

Email

Phone *

Date

TPA/Health Plan *

Employer (Name) *

Patient Name *

First

Middle

Last

Patient Gender

Date of Birth *

Patient Email

Patient Phone *

Patient Address *

Address Line 1

Address Line 2

City

State

Zip Code

Insured/Dependent *

Insured ID *

Group Number

Insured's Name

Diagnosis *

Date of Diagnosis

Stage of Diagnosis (optional)

Has treatment been started?

Has treatment been completed?

Additional Notes (optional)

Primary Care Physician

Name

First

Last

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Oncologist

Name *

First

Last

Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Facility

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Other Contacts

Do you have the contact information for the patients:

Surgeon
Radiation Oncologist
Neither

Surgeon

Name

First

Last

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Radiation Oncologist

Name

First

Last

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Treatments

Recent Treatment Request(s)

Recent Treatment Approval(s)

Known Treatment History

Case Manager

Referred by (company)

Date

Referred by contact

Phone

Additional Information

Other Notification/Additional Information

Comments/Questions

Please securely email or fax completed information to CancerCARE at: cancermanagement@cancercareprogram.com or 503.640.6277 Please include any medical records you have for this Member

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Cancer CARE for Life is here for you at every stage. We focus on cancer prevention, early detection, and ongoing support. From the very first day, you are never alone. Our team provides clear education, trusted medical expertise, and caring support.

Contact Information

(877)640-9610
connections@cancercareforlife.com
4660 NE Belknap Court, Suite 209
Hillsboro, Oregon 97124

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