Patient Information
Patient First Name
*
Patient Last Name
*
Birthdate:
*
-
Month
-
Day
Year
Date
Legal Sex
Male
Female
Is the patient aware of the referral to the the University of Cincinnati Cancer Center?
*
Yes
No
Is the patient currently admitted in a hospital?
*
Yes
No
If so, where?
Name of hospital
Preferred Phone Number
*
-
Area Code
Phone Number
Phone Type
*
Please Select
Cell/Mobile
Home
Work
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is an interpreter needed?
Yes
No
Preferred Language for Healthcare
Diagnosis and Reason for Consult or Treatment Information
Referring Diagnosis
Please Select
Acoustic Neuroma
Adrenal Disease
Alopecia Areata
Anal Cancer
Aplastic Anemia
Appendix Cancer
Basal Cell Cancer
Bladder Cancer
Brain Tumor
Breast Cancer
Breast Cancer - Inflammatory Breast Cancer
Breast Cancer - Undiagnosed
Carcinoid Tumor
Cervical Cancer
Colon Cancer
Cutaneous Lymphoma (CL)
Ear Cancer
Endocrine Tumor
Endometrial Cancer
Esophageal Cancer
Esophageal Cancer - metastatic
Ewing's Sarcoma
Eye Cancer
Fallopian Tube Cancer
Gallbladder / Bile duct Cancer
Germ Cell Tumor
Kidney Cancer
Leiomyosarcoma
Leukemia
Liver Cancer
Lung Cancer
Lymphoma
Melanoma
Mesothelioma
Multiple Endocrine Neoplasia
Multiple Myeloma
Myelodysplastic Syndrome (MDS)
Myeloproliferative Disease (MPD)
Nasal / Sinus Cancer
Neuroendocrine Tumor
Neurofibroma/Neurofibromatosis
Oral Cancer - mouth, lip, tongue
Osteosarcoma
Other
Ovarian Cancer
Pancreatic Cancer
Pancreatic Cyst
Parathyroid Disease
Pelvic Mass
Penile Cancer
Peritoneal Cancer
Pituitary Tumor
Prostate Cancer
Rectal Cancer
Retinoblastoma
Rhabdomyosarcoma
Salivary Gland Cancer
Sarcoma
Skin Cancer
Skull Base Tumor
Small Lymphocytic Lymphoma (SLL)
Soft Tissue Sarcoma
Spine Tumor
Stomach Cancer
Testicular Cancer
Throat Cancer
Thymoma
Thyroid Cancer
Thyroid Nodules
Unknown Primary
Uterine Cancer
Vaginal Cancer
Vulvar Cancer
Waldenstrsm's Macroglobulinemia
Wilms Tumor
von Hippel Lindau Disease
Other
Other Referring Diagnosis
Reason for Referral
Confirmed Diagnosis?
Yes
No
Diagnosis Method
Please Select
Biopsy
Exam
Imaging
Are you requesting any of the specific services? If so, please select which one(s).
Brachytherapy
Clinical Trial Evaluation
Consult for New Diagnosis
Diagnostic Imaging
Oncology Supportive Care
Proton Therapy
Radiation Oncology
Second Opinion
Stem Cell Transplant/Cellular Therapy
Survivorship
Are you requesting a specific University of Cincinnati Cancer Center physician? If so, please place their name here.
Referring Physician Information
(Optional)
Is this a physician referral?
Yes
No
Provider NPI Number (optional)
Physician First Name
Physician Last Name
Physician Phone Number
-
Area Code
Phone Number
Physician Fax Number
-
Area Code
Phone Number
Physician Email
Confirmation Email
example@example.com
Preferred Method of Initial Contact
Please Select
Phone
Fax
Email
Are you the patient's PCP?
Yes
No
Do you (provider) utilize Care Everywhere to exchange health information?
Yes
No
Patient Insurance Information
(Optional)
Primary Insurance
Please Select
Aetna
Blue Cross
Cigna
Humana
Medicaid Traditional - Texas
Medicare Part A/B
TRICARE
United Healthcare
Other
I don't have insurance
If other, please specify
Name of Primary Insurance Holder
First Name
Last Name
Subscriber's Birthdate
-
Month
-
Day
Year
Date
Subscriber Number
Member Number, if different than subscriber number
Group Number
Name of any additional or supplemental medical insurance
Submit
Should be Empty: