Provider Referral Form - Crossroads4Hope

Crossroads4Hope is a partner of your healthcare provider. Our services are offered to individuals affected by cancer at no charge thanks to the generosity of our donors and funders. All information is kept strictly confidential.

If this referral is for a minor, please complete with parent/guardian information.

CONTACT INFORMATION

Date

Name*

First Middle Last

Date of Birth*

Address*

Street Address City State ZIP Code

Email*

Enter Email Confirm Email

Primary Phone Number*

Primary Phone Type*

Home
Mobile
Work

I am a:*

Person with cancer
Family/friend of person with cancer
Person in bereavement
Parent of child diagnosed

Are there children in the home?*

Yes
No

Indicate Ages of Children*

DIAGNOSIS INFORMATION

Primary Diagnosis*

You selected "Other" Cancer type. Please describe:*

Date of Diagnosis*

Diagnosis Type*

New (First time diagnosed)
Recurrent

Is your cancer:*

Early Stage
Advanced/metastatic

Treatment Stage*

Active
Post

REFERRAL INFORMATION

Institution*

Person Referring*

Referral notes or other important considerations

(i.e. language other than English, family circumstances, diagnosis details, etc.)

Preferred Language*

You chose "Other", please specify:*

Please check any that apply:

VERBAL AUTHORIZATION

The individual listed below has received verbal authorization, by the patient above, to disclose the protected health information described in this referral to Crossroads4Hope, and approves Crossroads4Hope to initiate direct follow-up. The patient is aware that, under N.J.S. 45:14B-28, they may refuse to permit the disclosure of confidential communications between themselves and their physician under many circumstances. The patient waives, for the above purposes only, whatever right of confidentiality they may have. The patient is also aware that they may revoke this authorization at any time and that, while their revocation will not affect disclosures of information that occurred prior to the revocation, it will be effective as to subsequent requests for disclosure.The patient understands that Crossroads4Hope may return this form or communicate directly with this office for care coordination or to indicate whether Crossroads4Hope provided an additional referral.

The following individual is the person we will contact to follow-up on this referral:

Phone:*

Email:*

Referral Completed By*

Date*