Libby's Legacy: P.A.L.S Application

Application for Patient Advocate Liaison Services

Please complete the following application to request Patient Advocate Liaison Services. All information will be kept confidential.
APPLICANT INFORMATION
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Please select your status
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
County
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Best phone to call
Please enter a valid phone number.Format: (000) 000-0000.
Best time to call
Email address
example@example.com
Do you have access to computer?
Preferred method of contact
Ethnicity/Race
How do you identify?
Who referred you to us today?
Have you ever used Libby’s Legacy for breast health services?
Employment Information
Please select your employment status
Employer Name (if employed)
Occupation
If you are not working, why?
Year last worked
Health Information
Do you have insurance?
Name of insurance
ID #
Oncologist
Oncologist Office Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Oncologist Office Phone
Please enter a valid phone number.Format: (000) 000-0000.
Treatment facility
Treatment Facility Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Treatment Facility Phone
Please enter a valid phone number.Format: (000) 000-0000.
Date of diagnosis

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Diagnosis
Stage
Are you currently undergoing any treatments?
If yes, please explain
Date treatment began or will begin

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Do you currently have a support system through either family or friends?
If you do have a support system, please describe
What services do you need
Physician Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Do you have any special needs or accommodations?
Emergency Contact
Emergency Contact Name

First NameLast Name
Relationship
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Email Address (optional)
example@example.com
Patient’s Statement of Understanding
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature of Patient / Responsible Party
Should be Empty:

Application for Patient Advocate Liaison Services

APPLICANT INFORMATION

Employment Information

Health Information

Emergency Contact

Patient’s Statement of Understanding