Thank you for your interest in The University of Texas MD Anderson Cancer Center. The International Center will be happy to assist you in securing an appointment.

Dear Patient,

Thank you for your interest in The University of Texas MD Anderson Cancer Center. The International Center will be happy to assist you in securing an appointment.

Please complete the attached forms and fax them to [phone]. Be sure to include with the forms the following information:

· Typed pathology reports to include the specimen or accession numbers and the pathologists name and facility address

· Typed surgical reports

· Typed laboratory reports

· Typed radiology (x-ray, CT scans, ultrasound, bone scan, mammograms, and MRI) reports

· Typed medical and treatment history summary prepared by your physician to include records of chemotherapy and radiation treatments

· Copy of the passport showing name and date of birth of the patient

Patients are required to travel to MD Anderson for our physicians to determine the extent of disease and make appropriate treatment recommendations. However, in some cases after reviewing the requested information our physicians may recommend that you not travel to Houston.

Please be advised that it may take a minimum of 3-5 business days for us to inform you of your appointment from the time we receive your completed forms and your reports. In the meantime, if you have any questions, please do not hesitate to call your International Patient Assistant [phone]. The International Center is happy to assist you with housing and ground transportation arrangements in Houston, as well as provide information that may be helpful as you make your travel arrangements. Should you have any other special needs or requests please let us know.

Sincerely,

Cynthia Gonzalez

Patient Representative

International Center

[e-mail]

Please answer all of the following questions. It may be helpful for you to have your physician assist you in answering these questions. Please type or print clearly.

PATIENT INFORMATION Today’s Date: ____________________________

Patient's name: (first) ___________________________________ (last) ___________________________________

Date of birth (D/M/Yr): ________________________________ Sex: ____________________________________

Birth City/State/Province: ___________________________________Birth Country: ________________________

Diagnosis: ____________________________________________________________________________________

Date of diagnosis ___________________ is this an original diagnosis or a recurrence? ______________________

If this is a recurrence, what is the date of the original diagnosis? _________________________________________

How was the disease diagnosed? Surgical Biopsy _______ Fine Needle Aspiration _____ Resection ___________

Has the disease spread to other organs? Yes ________ No _____________

If yes, please specify where ________________________ and the date it was discovered__________________

Is the patient ambulatory (walking, out of bed) more than 50% of the day? Yes ______ No ______

Is the patient able to take care of self without assistance? Yes ______ No ______

Does the patient require the use of oxygen? Yes ______ No ______

Is the patient jaundiced (skin and/or eyes yellow)? Yes ______ No ______

Does the patient have ascites (liquid abdominal cavity/swollen)? Yes ______ No ______

Does the patient have difficulty eating? Yes ______ No ______

Has the patient had surgery related to above-mentioned diagnosis? Yes _______ No ______

If yes, please give surgery date and type of procedure ___________________________________________

Has the patient received Chemotherapy? Yes ______ No ______

If yes, please list specific chemo agents and doses__________________________________________________

What is the date of the last treatment? __________________________

When is the next treatment scheduled? _________________________

Has the patient received Radiotherapy? Yes ______ No ________

What were the doses and cycles? ______________________________________________________________

What is the date of the last treatment? ______________________________________________________

When is the next treatment scheduled? _________________________

What treatment does the local physician currently recommend? ______________________________________

Has patient suffered from heart problems? Yes ______ No _______

When was the last MRI or CT scan? ____________________________________________________________

(Please note: MRI for brain tumor patients must have been done within the last 30 days)

What type of service are you requesting from M. D. Anderson (second opinion, evaluation, consultation?

Treatment? other? ____________________________________________________________________________

PATIENT DEMOGRAPHICS / CONTACT INFORMATION

Marital status: _________________________ Spouse’s name: _________________________________________

Religious preference: ______________________________Language: ___________________________________

Patient's address: _____________________________________________________________________________

City: ___________________________________________State/Province________________________________

Country: ___________________________________________Zip/Postal code_____________________________

Patient's telephone (starting w/country & area code) Home: ____________________________________________

Fax: ______________________________________Work: ___________________________________________

E-mail: _____________________________________________________________________________________

Contact person(s): Name: ______________________________________________________________________

Relation to patient: _________________________ Home: _____________________________________

Fax: ____________________________________ Cell: _______________________________________

Emergency contact (other than spouse) Name: ______________________________________________________

Relation to patient: __________________________Home: ____________________________________

Fax: ____________________________________ Cell: _______________________________________

Do you have insurance? ________________________________________________________________________

Are you requesting a specific physician at M. D. Anderson? ___________________________________________

If yes, which physician? _________________________________________________________________

(Please note that requesting a specific physician may delay your appointment)

Preferred appointment date: ___________________________________________________________________

Do you have a visa? _______________ Country or Countries issuing passport(s): __________________________

FAX COPY OF PASSPORT SHOWING NAME WITH MEDICAL DOCUMENTS

TREATING PHYSICIAN INFORMATION

Please complete the following information about the physician currently treating you. Please type or print clearly.

Physician’s Last Name: ________________________________________________________________________

Physician’s First Name: ________________________________________________________________________

Physician’s Specialty: _________________________________________________________________________

Hospital/Clinic your physician is associated with: ___________________________________________________

Physician’s Street Address: _____________________________________________________________________

­­­­­­­___________________________________________________________________________________________

Cit/State/Province: ________________________________________ Zip Code: __________________________

Country: _______________________________Phone: ______________________________________________

Fax: ___________________________________E-mail: _____________________________________________

Would you like us to keep your treating physician updated regarding your visit? ___________________________

Was this the physician that referred you to M.D. Anderson? __________. If not, please complete the next section regarding the physician who referred you.

REFERRING PHYSICIAN INFORMATION

Physician’s Last Name: ________________________________________________________________________

Physician’s First Name: ________________________________________________________________________

Physician’s Specialty: _________________________________________________________________________

Hospital/Clinic your physician is associated with: ____________________________________________________

Physician’s Street Address: _____________________________________________________________________

­­­­­­­____________________________________________________________________________________________

Cit/State/Province: ________________________________________ Zip Code: ___________________________

Country: _________________________________Phone: ____________________________________________

Fax: ___________________________________E-mail: ______________________________________________

Would you like us to keep your referring physician updated regarding your visit? __________________________

INTERNATIONAL INSURANCE

Name of policyholder: ________________________________________________________________________

(as it appears in the insurance policy contract)

Name of patient: _____________________________________________________________________________

(as it appears in the insurance policy contract, if the patient is listed as one of the policyholder’s dependents, i.e., if the patient is not the policyholder)

Policyholder’s date of birth (dd/mm/yyyy): ____________________________________________________________

(as it appears in the insurance policy contract, if the policyholder is not the patient)

Name of insurance company: _____________________________________________________________________

Telephone number (U.S. telephone number of the insurance company): ___________________________________

Fax number (of the insurance company): ____________________________________________________________

Policy number: ________________________________________________________________________________

Group number: ________________________________________________________________________________

Mailing address (for sending insurance claims and account statements):

Street: _______________________________________________________________________________________

City: ________________________________________________________________________________________

Country: ______________________________________________ Zip code: ______________________________

Company where policyholder is employed (this information is necessary only if the insurance coverage is a benefit provided to the policyholder by his employer):

Company name: _______________________________________________________________________________

Address: _____________________________________________________________________________________

Telephone number: ____________________________________________________________________________

Policyholder’s position/title at this company: ________________________________________________________

Comments: ___________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________

Please check with your insurance company to see if MD Anderson will be able to bill them directly. If so, please send us a copy of your insurance card (front and back). In most cases, MD Anderson can only accept insurance coverage from insurance companies that have offices within the Unites States.

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Дата добавления: 2015-11-04