Get Patient Navigation Intake Form - Association Of Community Cancer ... - Accc-cancer

The Patient Navigation Intake Form is a vital document that helps ensure patients receive the appropriate support for their cancer journey. This guide will provide you with clear and detailed instructions on how to complete the form accurately and effectively.

Follow the steps to complete the Patient Navigation Intake Form.

1. Press the ‘Get Form’ button to access the intake form and open it in your selected editor.
2. Begin by filling in the patient's name, address, and telephone number(s) in the respective fields. Indicate whether messages can be left at the provided phone number by selecting 'Yes' or 'No.'
3. Provide the details of an emergency contact person and their contact number.
4. Inquire about the referral source for the patient and mark the appropriate option from the choices such as physician or hospital. If applicable, fill in the names and relevant center details.
5. Document what the doctor has communicated to the patient regarding their diagnosis and the biopsy date/result.
6. Indicate whether the patient has health insurance, and if so, specify the type by selecting from the provided options including private, Medicare, Medicaid, and others.
7. Move to the 'Potential Problems/Barriers to Care' section. This helps identify any concerns the patient may have for follow-up. Check any applicable issues related to health insurance, transportation, physical needs, or communication needs.
8. Detail any disease management and treatment compliance issues the patient may be facing.
9. Enter any family history relevant to cancer for the patient.
10. List supportive services or referrals that may be beneficial for the patient.
11. Record any scheduled appointments and their corresponding dates for various tests or consultations.
12. Document the plan of care and follow-up steps in the provided fields.
13. Finalize by adding any additional comments in the comments section as needed.
14. Once the form is complete, you can save changes, download, print, or share the form.

Start filling out the Patient Navigation Intake Form online today for a seamless experience.