Get Hope Lodge Request Form: Complete All Fields - American ... - Cancer

This guide provides clear instructions for completing the HOPE LODGE REQUEST FORM to ensure a smooth application process for lodging at a Hope Lodge facility. By following these detailed steps, you can effectively complete the form online, ensuring all required information is accurately provided.

Follow the steps to successfully complete the HOPE LODGE REQUEST FORM.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor for completion.
2. Begin with the patient information section. Indicate if the patient is a first-time or returning guest, and provide the requested lodging start and end dates.
3. Fill in the patient's name, home address, date of birth, gender, phone numbers, city/state/ZIP code, and email address.
4. Provide the caregiver's name and their relationship to the patient.
5. If applicable, complete the optional patient information, including insurance type and ethnicity.
6. In the medical information section, provide the date of diagnosis, diagnosis or cancer site, type of treatment, frequency of treatments, treatment start date, and whether the patient is enrolled in a clinical trial.
7. List the treatment facility, referring professional's name, their title, contact numbers, and email address.
8. Provide the treating physician's name, along with their phone number.
9. Answer the questions related to infectious diseases for both the patient and caregiver, English comprehension, wheelchair accessibility needs, service animals, and any criminal history.
10. Complete the treating physician or social worker's statement, including their printed name, signature, and date.
11. Review all sections for accuracy and completeness before saving changes, downloading, printing, or sharing the form.

Complete the HOPE LODGE REQUEST FORM online today for a seamless lodging experience.