Hope Abounds - Medical Referral Form

Patient's first name*

Patient's last name*

Patient's phone number*

Patient's email address*

If the patient does NOT have an email address, please input patient'sfirstname_patient'slastname@noemail.com.

Please check where the patient is currently living.*

House

Apartment

Living with a friend/relative

Living in a shelter

Other

Please list the name of the shelter.

Patient's address line 1

Patient's address line 2

Patient's city*

Patient's county*

Patient's state/province*

Patient's ZIP/postal Code*

Patient's gender*

Female

Male

Prefer not to respond

Patient's ethnicity*

Hispanic/Latinx

Not Hispanic/Latinx

Prefer not to respond

Patient's race*

Native American or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Other

Prefer not to respond

Patient's date of birth*

Patient's age*

Parents'/Guardians' names*

Parents'/Guardians' phone number*

Parents'/Guardians' email address

Patient's date of diagnosis*

Patient's cancer diagnosis

Patient's cancer stage

Patient's treatment plan (therapies, how many times per week, etc.)*

Name/title/Practice Clinic of other medical professionals working with the patient (oncologist, surgery physician, radiologist, etc.)

Does the patient have health insurance?*

Yes

No

Please list the patient's health insurance(s).

For example: Medicare, Medicaid, BCBS, UnitedHealthcare, etc.

Organizations that have been applied to for the patient - please include date of application, application status, and funds received*

If you nor the patient has applied to any organizations, please write N/A.

Type of assistance requested from Hope Abounds (financial, transportation, emotional, etc.)*

Health care professional's name*

Health care professional's phone number*

Health care professional's email address*

Health care professional's fax number

Practice/clinic's name*

Practice/clinic's address line 1

Practice/clinic's address line 2

Practice/clinic's city*

Practice/clinic's county*

Practice/clinic's state/province*

Practice/clinic's zip code*

Do you have a letter of support? *

Yes, I will submit it below

No, I will email one to amanda@hopeabounds.org or fax it to (910) 778-1599.

Please upload the letter of support here.

On a professional letterhead, this must include the patient’s name, date of birth, cancer diagnosis, date of diagnosis, and detailed treatment plan including any therapies, medications, etc.

Is there anything else we should know that you'd like to add?

Signature

Today's Date

Medical Referral Form

PATIENT CONTACT INFORMATION

PATIENT DEMOGRAPHICS

PATIENT MEDICAL INFORMATION

Please be as detailed as possible!

HEALTH CARE PROFESSIONAL'S INFORMATION