Oncology Appointment Request

We are pleased to assist with your cancer care appointment needs. Please fill out all questions in the form below and someone will be in touch with you 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 317-621-2627 or 833-473-1483 (toll-free) or email us. We look forward to serving you!

For Providers: To refer a patient to us, please fill out this online provider referral form.

Patient Information

Have you received oncology care at Community Health Network in the past?

Yes

Patient First Name (*Required)

Patient Middle Name

Patient Last Name (*Required)

Address

City

State/Province

ZIP/Postal Code

Date of Birth (*Required)

Date of birth is required for scheduling. Patients must be age 18 or older.

Legal Sex

Preferred Phone Number (*Required)

Please include area code and format as ###-###-####.

Phone where patient may be reached is required. If no call-back number is available, please email OncologyIntakeCenter@eCommunity.com.

Phone Type

Email Address

Confirm Email Address

Retype email

Insurance Information

Do you have health insurance?

Yes

Insurance Information

Primary Insurance

Subscriber Name

Policy Number

Group Number

Claim Address

Claim Phone Number

Secondary Insurance

Subscriber Name

Policy Number

Group Number

Claim Address

Claim Phone Number

Additional Insurance

Subscriber Name

Policy Number

Group Number

Claim Address

Claim Phone Number

Medical Information

Preferred Location

Do you have a preferred cancer center/hospital campus for your appointment? Please note provider locations may vary.

Second Opinion?

Yes

Do you have a known diagnosis?

Yes

Diagnosis

Please briefly describe your diagnosis.

Were you referred to Community by a provider?

If yes, please enter the provider's information so we may contact them for more details if needed.

Yes

Referring Provider - Name

Referring Provider - Address

Referring Provider - Phone

Referring Provider - Fax