ADDITIONAL INTAKE FORM ADDITIONAL INTAKE FORM Date of Request MM slash DD slash YYYY Coordinator's Name Hospital / Center Providing Cancer Treatment Coordinator Email Address Coordinator Phone NumberPatient First Name Patient Last Name Patient Date of Birth MM slash DD slash YYYY Patient Address Patient Address 2 Patient City Patient State Patient Zip Patient County Patient Cell PhoneRace----African AmericanCaucasianHispanicAsianNative AmericanOtherPatient Work PhonePatient Home PhonePatient's Email Address Gender----Select OneMaleFemaleAge Health Insurance----Commercial (HMO, PPO, BCBS, etc)MedicaidMedicareNoneMarital Status----SingleMarriedDivorcedWidowedOccupation Does patient live alone?----YesNoNumber of Dependent Children Has patient received services from the Zaching Against Cancer Foundation this year?----YesNoType of Cancer Stage Date of Diagnosis Treatment - Please Check All That Apply Surgery Chemotherapy Radiation Other Caregiver Name (Complete this section only when requesting services for the caregiver) Caregivers Relationship to Patient Caregiver Date of Birth (MM/DD/YYYY) MM slash DD slash YYYY Caregiver Address 2: Caregiver Address Caregiver City Caregiver State Caregiver County Caregiver Zip Caregiver Work PhoneCaregiver Cell PhoneCaregiver Home PhoneCaregiver Gender----MaleFemaleCaregiver Race Caregiver Occupation Caregiver Marital Status----MarriedDivorcedSingleOtherCaregiver's Number of Dependent Children Has 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 Name Service Provider Contact Name Brief Description of Why Services Requested and Any Additional CommentsService Provider Address Service Provider Address 2 Service Provider City Service Provider State Service Provider Zip Service 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.
