For Referring Doctors

Text Size A A

E-Mail to a Friend






secret  Click to Play Audio


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). Download this PDF to view the complete list of SCCA/UW oncology providers by specialty.


Referring Physician
*:
*:
:
*:
Please check here if you are an SCCA Network Physician
      
Patient Details
:
:
:
:
:

*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.
Please screen this patient for the following Phase 1 Program trial at SCCA:

Imatinib and BKM120 for 3rd Line GIST Patients
A Multi-arm Dose-finding Phase Ib Multicenter Study of Imatinib in Combination With the Oral Phosphatidyl-inositol 3-kinase (PI3-K) Inhibitor BKM120 in Patients With Gastrointestinal Stromal Tumor (GIST) Who Failed Prior Therapy With Imatinib and Sunitinib

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) :  
  :
  :
  :

2) :
  :
  :
  :

3) :
  :
  :
  :

:



Enter the above text to validate. Click to Play Audio


Privacy Policy

03-07-2014   Oncology Referral Contact List (102kb)