Get the free Hereditary cancer program referral bformb - CAGC

AGENCY CHART No. SURNAME Female HEREDITARY CANCER PROGRAM REFERRAL FORM Date of Referral: GIVEN NAME Male BIRTHDATE (D×M/Y) HEALTH CARE PLAN No. (dd×mm/by) MAILING ADDRESS Referring Physician: Billing

How to fill out hereditary cancer program referral

Who needs hereditary cancer program referral?

1. Individuals with a family history of cancer: People who have a close relative (such as a parent or sibling) that has been diagnosed with cancer may be at an increased risk of developing cancer themselves. These individuals should consider seeking a hereditary cancer program referral to assess their risk and determine appropriate screening and prevention measures.
2. Those with a personal history of cancer: People who have already been diagnosed with cancer may benefit from a hereditary cancer program referral to determine if their cancer was related to an inherited gene mutation. This information can help guide their treatment decisions and identify any additional surveillance or prevention strategies that may be necessary.
3. Individuals with a known gene mutation: Some individuals may already know that they carry a specific gene mutation, such as BRCA1 or BRCA2, which are associated with an increased risk of breast and ovarian cancers. These individuals should seek a hereditary cancer program referral to receive personalized counseling and recommendations for managing their cancer risk.

How to fill out hereditary cancer program referral:

1. Obtain the referral form: Talk to your primary care physician or oncologist to request a hereditary cancer program referral form. They should be able to provide you with the necessary paperwork or direct you to where it can be obtained.
2. Complete personal information: The referral form will likely require you to fill out basic personal information, such as your name, date of birth, contact information, and insurance details. Provide accurate and up-to-date information to ensure a smooth referral process.
3. Provide medical history: The referral form may ask for information about your medical history, including any previous cancer diagnoses, surgeries, or treatments. Be thorough and provide as much detail as possible, as this information will help the hereditary cancer program assess your risk.
4. Document family history: It is crucial to provide a detailed family history of cancer on the referral form. Include information about any immediate family members (parents, siblings, children) and extended family members (grandparents, aunts, uncles, cousins) who have had cancer, specifying the type of cancer diagnosed and the age at diagnosis if available.
5. Attach relevant medical records: If you have any medical records, such as previous genetic testing results or pathology reports, that are pertinent to your cancer risk assessment, make sure to include them with the referral form. These records can provide valuable information to the hereditary cancer program specialists.
6. Follow submission instructions: Once the referral form is completed, follow the instructions provided on the form for submission. This may involve mailing the form to a specific address or submitting it electronically through a secure portal. Ensure that all required documents are included before sending.

Remember, the specific process for filling out a hereditary cancer program referral may vary depending on the healthcare provider or institution. It is always a good idea to contact the program directly for any additional instructions or clarification.

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What is hereditary cancer program referral?

Hereditary cancer program referral is a process of referring individuals with a suspected hereditary cancer risk to specialized programs for further evaluation and management.

Who is required to file hereditary cancer program referral?

Healthcare providers and genetic counselors are required to file hereditary cancer program referrals.

How to fill out hereditary cancer program referral?

To fill out a hereditary cancer program referral, healthcare providers and genetic counselors need to gather information about the patient's personal and family medical history, genetic testing results, and any relevant medical records.

What is the purpose of hereditary cancer program referral?

The purpose of hereditary cancer program referral is to identify individuals at increased risk for hereditary cancers, offer appropriate genetic testing and counseling, and provide personalized risk management strategies.

What information must be reported on hereditary cancer program referral?

Hereditary cancer program referrals must include detailed information about the patient's personal and family medical history, genetic testing results, and any relevant medical records.