Client Intake Client Information Name * First Middle Last Address Field Mailing Address * Address Line 2 City * County * Zip Code * Age Date of Birth * Email Address Home Phone Cell Phone Best Time to Call Household Size Dropdown — Select — Part Time Full Time Retired Disabled Unemployed Laid Off Child/Student & parents information below Employer City Phone Spouse/Significant Other Information Name First Last Email Address Home Phone Employer Cell Phone City May CAWC contact and share information with Spouse/Significant Other Yes No Medical Provider Information of Client Cancer Diagnostics Date of Diagnosis Cancer Physician (Oncologist/Radiologist) First Last Address Physician * Address Line 1 City * State * Zip Code * Physician Phone Extension Treatment Information: Current and Future What is your current or future treatment? Surgery Radiation Chemotherapy Hormones Other If Other Describe Patient Navigator? Enter name and phone Healthcare Coverage Medicare Traditional Medicare Advantage VA Benefits Medicaid Commercial/Private through Employer Commercial/Private through Healthcare Marketplace Check all that apply Additional Information Enter Commercial/Private Provider Information Prescription Coverage Yes No Have you sought Additional Financial Assistance? VA Benefits Job and Family Service Ohio H-Cap Hospital Charities Churches National Organizations Local Organizations What Organizations Enter National or Local Organizations, if applicable Organizational Information Hospital Physician Family/Friend Newspaper/Flier Other Cancer Assistance of Williams County (CAWC) is a nonprofit agency. Created to help cancer patients that live in Williams County. The requirement for financial assistance is: You must be a resident of Williams County, Ohio over 3 months. Be within 1 year of diagnosis and seeking active medical approved treatment that is under the care of a licensed Medical Doctor. Authorize the use or disclosure of health information from the Physician, and treatment location listed. Reasons for Financial Assistance Stoppage: Unnecessary duplication of services that would result in overpayment to client. Dishonesty regarding reimbursement. Clients that have entered into the Hospice period are no longer qualified for CAWC financial assistance. Residents in nursing homes are not eligible for financial services. In signing, I understand the information I supplied for intake is for the benefit of CAWC to provide services and to document outcomes. I also understand and abide by the above CAWC Policy. Authorized Signature___________________________________________ Date ____________ Signature Field Clear
