Patient Information Forms

ONLINE PATIENT INFORMATION FORM

Form Last Updated 2/10

Children’s Leukemia Foundation of Michigan (CLF) provides information, financial assistance, and emotional support to families affected by leukemia, lymphoma, and other malignant or potentially malignant disorders of the blood, bone marrow, and lymphatic system. Our services are free of charge and are available for both child patients and adult patients. Families must complete this form to be eligible for CLF’s services. Please call (800) 825-2536 with any questions or concerns.

ABOUT THE PATIENT

General Information

First Name:

Middle Initial:

Last Name:

Address:

City:

State:

Zip:

County:

Home Phone:

Cell Phone:

Where do you want to be contacted? Home Phone Cell Phone

Email:

Birth Date:

Gender: Male Female

Race (Optional):

Marital Status:

Spouse/Significant Other’s First Name:

Spouse/Significant Other’s Last Name:

 Employed Unemployed Retired Disabled Student Other

Employer:

Medical & Insurance Information

Diagnosis:

Diagnosis Date:

Bone Marrow/Stem Cell Transplant Date:

Treatment Center:

City:

State:

Health Professional Contact:

Title/Position:

Phone:

Does the Patient Have Health Insurance:
 Yes (If Yes, Please Continue) No (If No, Please Skip to the Next Section)

Does the Insurance Cover ANY of the Patient's Treatment Costs?
 Yes No

Does the Insurance Cover ANY of the Patient's Prescription Costs?
 Yes No

Primary Health Insurance:

Name of Policy Holder:

Secondary Health Insurance:

Name of Policy Holder:

Does the Patient Have Medicare?
 Yes No Pending

Does the Patient Have Medicaid?
 Yes* No Pending

*(Spend Down? $: )

COMPLETE IF THE PATIENT IS A CHILD (UNDER 18)

Guardian Information
(Only list the address if it is different then the patient's)

Guardian First Name:

Last Name:

Relationship to Patient:

Address:

City:

State:

Zip:

Contact Phone:

Email:

Employer:

Guardian First Name:

Last Name:

Relationship to Patient:

Address:

City:

State:

Zip:

Contact Phone:

Email:

Employer:

COMPLETE IF THE PATIENT IS AN ADULT (18 OR OVER)

Family Contact Person Information

First Name:

Last Name:

Relationship to Patient:

Address:

City:

State:

Zip:

Contact Phone:

Email:

ADDITIONAL FAMILY INFORMATION - CHILD & ADULT PATIENTS

Total Number of Children in the Household:

Total Number of Adults in the Household:

ESTIMATED ANNUAL FAMILY INCOME:
$

For Adult Patients, List Names/Ages of Children Still Living at Home:

For Child Patients, List Names/Ages of Siblings Still Living at Home:

How Did Your Family Hear About CLF?

I certify that this information is true to the best of my knowledge as of the date indicated below. I understand that Children’s Leukemia Foundation of Michigan is a non-profit, community organization.

Provision of services is subject to approval by the CLF Board of Directors and may be discontinued at any time with or without notice. CLF will contact me upon receipt of my completed application.

Name:

Relationship to Patient:

Date:

COMPLETION OF THIS SECTION IS OPTIONAL

Please circle the extent to which you agree or disagree with the following statements:

I feel like I need more information about the patient’s illness and surrounding issues.
 Strongly Disagree Disagree Neutral Agree Strongly Agree
Comments:

The patient’s illness has had an effect on our family’s financial status.
 Strongly Disagree Disagree Neutral Agree Strongly Agree
Comments:

I have a good emotional support “system” to help me get through the stresses and strains of the patient’s illness.
 Strongly Disagree Disagree Neutral Agree Strongly Agree
Comments:

Please check all that apply:
I'd like to learn more about...
 The diagnosis Communicating with the health care team Emotional aspects of coping with serious illness Treatment options facing Insurance/Benefits issues Opportunities to interact with peers' similar circumstances Side effects Financial assistance

Please use the space below for any additional comments or concerns: