Provider Referral - New Patient Oncology Appointment

Community Health Network is pleased to assist with your patient's oncology appointment needs. Please fill out the information in the form below and upload any relevant documentation. You may also fax documents to us at 317-355-8712.

A member of our team will be in touch with the patient to schedule an appointment.

If you are unable to provide all details requested below, or have questions about appointments, please call our oncology referral phone line at 317-621-2638 or email us. We look forward to serving you!

Referring Provider Information

Referring Physician Name (*Required)

Practice Name

Practice Contact

Phone Number (*Required)

Fax Number

Email Address

Patient Information

NOTE: Patient's name, date of birth and a contact phone number are required to submit this form.

Patient First Name (*Required)

Patient Last Name (*Required)

Gender

Date of Birth (*Required)

Preferred Phone Number (*Required)

Please include area code. Phone where patient may be reached is required.

Phone Type

Address

City/Town

State

ZIP Code

Insurance Information

Would you like to add health insurance details for this patient?

Yes

Insurance Information

Primary Insurance

Subscriber Name

Subscriber ID

Group Number

Claim Address

Phone Number

Secondary Insurance

Subscriber Name

Subscriber ID

Group Number

Claim Address

Phone Number

Other Contact Information

First Name

Last Name

Relationship to Patient

Phone

Diagnosis

Does patient have a confirmed cancer diagnosis? (*Required)

Yes

Diagnosis and Reason for Consult/Treatment (*Required)

Upload Documentation

If desired, you may upload up to five (5) documents related to the patient's care or diagnosis (lab, imaging, biopsy reports, etc.).

Fax: You may also fax documentation to us at 317-355-8712.

Maximum 5 files.
256 MB limit.
Allowed types: rtf pdf doc docx.

Appointment Preferences

Preferred Provider

Preferred Location

Is there a preferred cancer center/hospital campus for the appointment? Please note provider locations may vary.