Get Cancer Notification Form

Filling out the Cancer Notification Form online is a crucial step in contributing to public health data regarding cancer diagnoses. This guide provides clear instructions to help users navigate each section of the form effectively.

Follow the steps to complete the Cancer Notification Form online with ease.

1. Press the ‘Get Form’ button to access the Cancer Notification Form and open it in your designated editing platform.
2. Fill in the patient information section, including the patient's name (last, first, middle), race, physical address at diagnosis, social security number (if available), date of birth, and sex. Make sure to select the appropriate options for race and sex.
3. In the Hispanic origin section, specify whether the patient is Hispanic or Non-Hispanic.
4. Provide cancer information by attaching the pathology report and filling in details such as the date of diagnosis, primary site, laterality, and vital status (alive or deceased). Include the date of last contact or death.
5. Indicate the pathology details, including the extent of the tumor using terms such as in-situ or localized. Additionally, describe any information related to the stage at diagnosis.
6. Address the cancer treatment question by indicating whether the patient received treatment. If yes, provide details about surgery, radiation, systemic treatments, or other types of treatment, including the type and start date.
7. Fill in whether the patient had treatment in a hospital or surgical facility and provide the name of the facility if applicable.
8. Complete provider information by entering the name and phone number of the practitioner as well as the person completing the form.
9. Finally, save your changes, and choose to download, print, or share the completed form as necessary.

Complete the Cancer Notification Form online today to contribute to vital cancer research and public health efforts.