Get Fccc International Patient Services Packet 2017-2026

Filling out the FCCC International Patient Services Packet online is a critical step for patients seeking oncology assessments and treatments at Fox Chase Cancer Center. This guide will provide you with clear instructions to ensure you complete the form accurately and efficiently.

Follow the steps to complete the FCCC International Patient Services Packet.

1. Use the ‘Get Form’ button to access the FCCC International Patient Services Packet online.
2. Begin by entering the date of completion, ensuring you fill in the month, day, and year accurately.
3. Provide your first and last name in the designated fields before proceeding to the gender section.
4. Select your gender option from the available choices: female or male.
5. Input your date of birth in the specified format, including the month, day, and year.
6. Indicate your country of origin or residency, ensuring it is clearly stated.
7. Enter your height and weight, specifying the units of measurement.
8. If you require an interpreter, provide the language needed in the appropriate field.
9. Fill out your phone number, ensuring to include area codes, followed by your email address.
10. Complete your address details accurately without leaving any necessary fields blank.
11. For payment information, indicate whether you are a self-pay patient or if you have international health insurance, and provide the insurance ID number if applicable.
12. Detail your original cancer diagnosis and the date, alongside a list of treatments you have received, including chemotherapy, surgery, radiation, or others.
13. Select your current performance status by checking the relevant box based on your ability to engage in normal activities.
14. Choose the type of service you are requesting, such as a remote second review, second opinion visit, treatment, or clinical trial.
15. Provide any additional details about your US visa needs and your trip details, including arrival and departure dates.
16. Respond to whether you will be submitting medical records, a disc with images, or pathology material for review.
17. Fill out your contact information, including the contact name, relationship to the patient, phone number, email address, and address.
18. Indicate how you learned about Fox Chase Cancer Center and include any questions, comments, or requests in the designated field.
19. Review the completed form for any inaccuracies before saving your changes, downloading, printing, or sharing it as needed.

Complete your FCCC International Patient Services Packet online now to ensure a smooth appointment scheduling process.