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Physician Referral Form

To refer a patient to SCCA, call (206) 288-SCCA (7222) or complete the form below. SCCA also offers U-Link, a secure system that allows referring physicians access to information about their patients.

Referring Physician
*Your Full Name:
*Phone Number:
Fax Number:
*E-Mail Address:
Please check here if you are an SCCA Network Physician

Patient Details
*Full Name:
*Date of Birth:
*Patient Phone Number:
*Patient Insurance:
*Diagnosis:

*Management of Care

	Please assume complete management of patient.
	Please assume a subset of care. We have developed a plan for the patient and would like you to review for input.
	We would like your opinion only.

*Purpose of visit or consult:

Referral to Specialty Service
	Breast Cancer
	Gastrointestinal Cancer
	Gynecologic Cancer
	Head, Neck and Lung Cancer
	Hematology
	Leukemia/Lymphoma
	Marrow/Stem Cell Transplant
	Prostate Cancer
	Renal and Melanoma
	Sarcoma
	Other:

*Patient Files

	We will send files. Films and slides should be sent to: Seattle Cancer Care Alliance, Intake Office, E2-102, 825 Eastlake Ave E, Seattle, WA 98109.
	We will fax files. Files should be faxed to: 206-288-1025.

Files should include medical records pertaining to the patient's original diagnosis through present and any treatment thus far. This includes chart notes, pathology reports, and radiology reports, laboratory reports for the last six months, surgical reports and treatment reports/summaries (ie: chemo flow sheets, radiation treatment reports).

Other Treating Physicians (optional)

1)	Physician's Name:
	Specialty:
	Phone Number:
	Fax Number:

2)	Physician's Name:
	Specialty:
	Phone Number:
	Fax Number:

3)	Physician's Name:
	Specialty:
	Phone Number:
	Fax Number:

Additional Comments:

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Driving directions to SCCA on South Lake Union.

Patient Guide to Clinical Studies

Find out more about clinical studies, what they are, and how to participate in them.

Careers

SCCA offers a variety of job opportunities in a broad range of disciplines.

Seattle Cancer Care Alliance
825 Eastlake Ave. E, P.O. Box 19023, Seattle, WA 98109-1023
(206) 288-SCCA (7222), contactus@seattlecca.org

© 2004-2008 Seattle Cancer Care Alliance. All rights reserved. Disclaimer.
Seattle Cancer Care Alliance unites the doctors from Fred Hutchinson Cancer Research Center, UW Medicine, and Seattle Children's to form a world-class treatment center that provides advanced therapies and clinical studies for cancers and other blood disorders.