Request For Services Form | Cancer Care & Support

Dempsey Center›Referring Provider Hub›Request For Services Form

Healthcare Provider Request for Services

I request that Dempsey Center contact the patient listed below to schedule an orientation for virtual or in-person cancer support services. Such services may* include counseling, support groups, educational workshops, programs for youth and families, nutrition consults and workshops, complementary therapy consults and workshops, and fitness consults and classes.

By completing this form you are confirming that the referred person has given consent to be contacted by the Dempsey Center.

*Please note, Client eligibility for services with the Dempsey Center will be determined based on your patient’s geographic location and specific cancer impact, certain services referenced above may not be available. Please do not promise or guarantee any Dempsey Center services will be available for your patient.

INFORMATION ABOUT PERSON BEING REFERRED

Client Name:(Required)

Client Date of Birth:

Parent/Legal Guardian Name:

REQUIRED if client is under 18 years old

Client / Parent Phone:(Required)

Okay to Leave Message:(Required)

YES

Client Status:

Active Treatment

Post Treatment

Caregiver / Loved One

Treatment Received:

Chemo

Radiation

Surgery

Relationship to Cancer Patient:

Diagnosis:

Date of Diagnosis, Recurrence, or Loss:

INFORMATION ABOUT FACILITY MAKING REFERRAL

Name of Provider:(Required)

Practice or Hospital:(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Provider Phone:(Required)

Provider Fax:

Provider Email:(Required)

Attestation:(Required)

By checking this box and submitting this request, I attest that I am authorized to make this request on behalf of the patient and/or the referring practice; that the patient has been informed of and agreed to this referral to the Dempsey Center for potential supportive cancer care services; and that the information provided is accurate to the best of my knowledge and is being shared for care coordination purposes.
I understand that the Dempsey Center may use this information to review the request, contact the patient, assess potential service needs, coordinate care as appropriate, and communicate with the referring practice for related care coordination needs. I understand that this request is not for emergency, urgent, or crisis intervention services.

I agree

Date or Request:(Required)

Healthcare Provider Request for Services

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