Kentucky CancerLink Patient Referral Form

Kentucky CancerLink Patient Referral Form

Phone: 859-309-1700 Fax: 859-368-8418
Referral Information
Date*

MonthDayYear
Date
Organization*
Referring Navigator*
Referring Navigator Phone #*
Referring Navigator Email*
example@example.com
Patient Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Zip code*
County*
Email
example@example.com
Race/Ethnicity*
Sex*

MaleFemale
Language Note

English SpeakingSpanish Speaking OnlyOther
Birth Date MMDDYYYY*

MonthDayYear
Date
Social Security Number
Required for those needing a colon/lung cancer screening
Cell Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Okay to Leave Messages on Phone*

YesNo
Discussed HIPAA*

YesNo
Primary Insurance*

MedicaidMedicareWellCareUninsuredOther
Secondary Insurance

MedicaidMedicareWellCareOther
Emergency Contact Name
Emergency Contact Phone
Relationship to Patient
Number In Household*
Annual Household Income*
Smoking History?*

Current SmokerNeverPrevious SmokerUnknown
Interested in quitting?

YesNo
Cancer Diagnosis Information

(If Applicable)
Cancer Type
Date of Cancer Diagnosis MMYYYY

MonthDayYear
Date
Current Stage
Treatment Facility
HOW CAN WE HELP YOUR PATIENT?
Patient Services Referral
Procedure Referral
Does your patient need assistance with a service not listed above?
At the moment our colon program has been paused, this means we are unable to provide colonoscopies to patients. We hope to get this resolved soon and will reopen the portal when the program is running again.

Thank you for your understanding,

Kentucky CancerLink
Due to lack of funding our gas card/transportation assistance program has been paused, this means we are unable to provide gas cards or other forms of transportation assistance to patients. We hope to get this resolved soon and will reopen the portal when the program is running again.

Thank you for your understanding,

Kentucky CancerLink
Physician Information
Physicians Name
Facility Name and Location
Fax #
Facility Phone #
Address

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Please attach any necessary documents below

Including mammogram/ultrasound, lung screening orders and lymphedema measurements helps the timeliness in which we can assist your patients
Cancelof
Should be Empty:

Kentucky CancerLink Patient Referral Form

Referral Information

Patient Information

Cancer Diagnosis Information

HOW CAN WE HELP YOUR PATIENT?

Physician Information