For Referring Doctors

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. (* denotes required field).

Referring Physician *Your Full Name: *Phone Number: Fax Number: *E-Mail Address: Please check here if you are an SCCA Network Physician        Bozeman Deaconess Cancer Center, Bozeman MT Cascade Cancer Center, Kirkland WA Clinic Cancer Care, Great Falls MT MultiCare Regional Cancer Center, Tacoma WA Olympic Medical Center, Port Angeles/Sequim Overlake Hospital Medical Center, Bellevue WA Providence Alaska Medical Center, Anchorage AK Skagit Valley Hospital, Mt. Vernon WA Wenatchee Valley Medical Center, Wenatchee WA	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 Records We will send records. Records should be sent to: Seattle Cancer Care Alliance, Intake Office, E2-102, 825 Eastlake Ave E, Seattle, WA 98109. We will fax records. Records 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:
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