Records Requested

In order to review any potential participant for eligibility, we will need to collect the following records.

NOTE: * Indicates necessary record.

From the patient

• Patient DEMOGRAPHIC SHEET *
• List of ALL MEDICATIONS patient is taking for any reason *
• Patient self-referral form

Forms for Records Request

Please feel free to utilize the attached forms when sending in records for review. FedEx numbers should only be used for sending radiology discs and medical records if necessary.

Medical Records Request Fax Form

Diagnostic Imaging Request Form

From the physician

• Original HISTORY AND PHYSICAL from diagnosis *
• DISCHARGE/ADMIT histories and physicals
• Latest PROGRESS NOTES *
• ORIGINAL PATHOLOGY REPORT with phone number for the Pathology Department *
• All other PATHOLOGY REPORTS
• OPERATIVE NOTES
• Latest labs: CBC and METABOLIC PANEL INCLUDING LIVER AND KIDNEY FUNCTION *
• Most recent IMAGING REPORTS showing progression with phone number of the Radiology Department *
• List of CHEMOTHERAPIES patient has received *