ADDITIONAL INTAKE FORM ADDITIONAL INTAKE FORM Date of Request MM slash DD slash YYYY Coordinator's NameHospital / Center Providing Cancer TreatmentCoordinator Email Address Coordinator Phone NumberPatient First NamePatient Last NamePatient Date of Birth MM slash DD slash YYYY Patient AddressPatient Address 2Patient CityPatient StatePatient ZipPatient CountyPatient Cell PhoneRace----African AmericanCaucasianHispanicAsianNative AmericanOtherPatient Work PhonePatient Home PhonePatient's Email Address Gender----Select OneMaleFemaleAgeHealth Insurance----Commercial (HMO, PPO, BCBS, etc)MedicaidMedicareNoneMarital Status----SingleMarriedDivorcedWidowedOccupationDoes patient live alone?----YesNoNumber of Dependent ChildrenHas patient received services from the Zaching Against Cancer Foundation this year?----YesNoType of CancerStageDate of DiagnosisTreatment - Please Check All That Apply Surgery Chemotherapy Radiation Other Caregiver Name (Complete this section only when requesting services for the caregiver)Caregivers Relationship to PatientCaregiver Date of Birth (MM/DD/YYYY) MM slash DD slash YYYY Caregiver Address 2:Caregiver AddressCaregiver CityCaregiver StateCaregiver CountyCaregiver ZipCaregiver Work PhoneCaregiver Cell PhoneCaregiver Home PhoneCaregiver Gender----MaleFemaleCaregiver RaceCaregiver OccupationCaregiver Marital Status----MarriedDivorcedSingleOtherCaregiver's Number of Dependent ChildrenHas Caregiver Received Services from the Zaching Against Cancer Foundation This Year? (does not affect eligibility)----YesNoAmount Requested for Services ($250 per person/per quarter cap)Services Requested (if requesting gift card indicate name of business desired)Reason for Referral (check all that apply) Too ill No family or friend available to provide Financial limitations Alleviate patient’s concerns about caring for family Service Provider Company NameService Provider Contact NameBrief Description of Why Services Requested and Any Additional CommentsService Provider AddressService Provider Address 2Service Provider CityService Provider StateService Provider ZipService Provider PhoneService Provider Required Form of Payment Check Credit Card How did you hear about the Zaching Against Cancer Foundation?File UploadMax. file size: 16 MB.
