Patient Review Checklists

Below is a comprehensive list of the essential forms and documentation required to initiate the review process. Please take note that all medical records must be submitted in ENGLISH, including the patient's full name and date of birth that match patient’s official ID. In cases where medical documents are composed in a foreign language, kindly ensure they are translated by a certified medical translator. Unfortunately, without the necessary medical records, we will be unable to proceed with the review/referral. It's essential that all medical records, images, and tissues/blocks include the exact full name and date of birth as indicated on the official ID. Our medical team might request specific tests or evaluations to be conducted before your visit to City of Hope. To submit your medical records, please email them to InternationalPatientCare@coh.org.

Kindly provide us with these medical records and information, or if you possess a typed CURRENT clinical summary from the physician, please ensure that the summary includes the following details:

  • Date of diagnosis
  • Pathology
  • Surgical history
  • Chemotherapy treatment history and response to chemotherapy or chemotherapy + radiation (list all regimens received and indicate if treatment was successful)
  • Results from the most recent imaging study (Please do not send the images, only the reports)
  • Laboratory results and physical condition
  • Recommended treatment or next steps
  • Operative notes from surgeon
  • All pathology reports containing prognostic markers (such as ER, PR, and HER2 NEU)
  • Recent laboratory reports
  • All recent image reports
  • A copy of the patient's passport displaying their name and date of birth
  • A copy of the insurance card, both front and back (if applicable)

Also, each type of cancer may require specific information to facilitate a thorough review. Therefore, we have developed tailored checklists for various types of cancer to guide patients in providing the necessary details for the review process and your first visit. Please select the relevant checklist based on the specific cancer type you are seeking evaluation for, from the list below. Your Patient Access Coordinator will follow up with you if specific images and tissue/blocks are needed for the review process or at your first visit.

Lung Cancer Patient Evaluation
Basic Text Field

Kindly provide us with these medical records and information (in English), or if you possess a typed CURRENT clinical summary from the physician, please ensure that the summary is translated into English includes the following details. Your Patient Access Coordinator will follow up with you if specific images and tissue/blocks are needed for the review process or at your first visit.

  • Diagnosis: date; stage; metastasis.
  • History of physical exam (previous all outside MD H&P’s, visit/clinic notes), family history, smoking history
  • Pathology (at least pathology reports and slides, may need more slides or blocks upon COH MD request)
  • Cytogenetic, Molecular reports, prognostic factors, immunophenotypesor subtype markers, Biomarker (EGRF mutation both either blood sample or tissue sample, ALK gene rearrangement, ROS1 gene maybe needed for patient with normal or unknown EGFR or ALK status, PD-L1 expression, BRAF V600E mutation, Hight-level MET amplication, RET gene rearrangements, and HER2 mutations), Proteomic test, flow cytometryreport
  • Surgical history& operative notes (size and location of tumor)
  • Chemotherapy or targeted therapy records and reports including:
    • All regimens (start & stop date)
    • Number of cycles
    • Chemotherapy response. Indicate if treatment fails and when
    • Current treatment plan
  • Last imaging study results, CD’s digital format (CT chest and upper abdomen and adrenals, PET/CT scan, Brain MRI)
  • Potential COH pathology team to review slides
  • Potential Radiologist to review imaging CDs
  • Pulmonary Function Test (pending from Pulmonary team -define which test will be ordered), Bronchoscopy, pathologic mediastinallymph node evaluation reports, or Biopsy
  • Laboratory results (at least CBC, CMP) and physical condition
Breast Cancer Patient Evaluation
Basic Text Field

Kindly provide us with these medical records and information (in English), or if you possess a typed CURRENT clinical summary from the physician, please ensure that the summary is translated into English includes the following details. Your Patient Access Coordinator will follow up with you if specific images and tissue/blocks are needed for the review process or at your first visit.

  • Diagnosis: date; stage; metastasis
  • Mammogram, Breast Ultrasound and/or Breast MRI date & result
  • Pathology review (excisional or core needle biopsy of primary lesion)
  • Tumor Estrogen/Progesterone receptor (ER/PR) status and HER2 status or additional Pathology or molecular testing
  • BRACA 1/ BRACA 2 mutation and additional genetic testing (for high-risk patients)
  • Recent Lab result or additional labs needed
  • Other imaging and scans (chest X-Ray, bone scan, CT scan of abdomen, PET scan, MRI Brain)
  • Past treatments (what were the treatment) and response treatments
  • Any staging done previously (T), (N), (M)
  • Family history, relevant past H&P
  • Patient’s current signs, symptoms and current treatment plan
Prostate Cancer Patient Evaluation
Basic Text Field

Kindly provide us with these medical records and information (in English), or if you possess a typed CURRENT clinical summary from the physician, please ensure that the summary is translated into English includes the following details. Your Patient Access Coordinator will follow up with you if specific images and tissue/blocks are needed for the review process or at your first visit.

  • Diagnosis: date; stage; metastasis.
  • History of physical exam (previous all outside MD H&P’s, visit/clinic notes), family history, life expectancy estimation
  • Pathology (Prostate biopsy, at least pathology reports and slides, may need more slides or blocks upon COH MD request)
  • Digital rectal examination(DRE) report
  • PSA level
  • Surgical history& operative notes (size and location of tumor)
  • Chemotherapy or radiation therapy records and reports including:
    •     All regimens (start & stop date)
    • Number of cycles
    • Chemotherapy response. Indicate if treatment fails and when
    • Current treatment plan
  • Last imaging study results, CD’s digital format (CT chest and upper abdomen and adrenals, PET/CT scan, Brain MRI)
  • Potential COH pathology team to review slides
  • Potential Radiologist to review imaging CDs
  • Pulmonary Function Test (pending from Pulmonary team -define which test will be ordered), Bronchoscopy, pathologic mediastinallymph node evaluation reports, or Biopsy
  • Laboratory results (at least CBC, CMP, PSA) and physical condition
Colon Cancer Patient Evaluation
Basic Text Field

Kindly provide us with these medical records and information (in English), or if you possess a typed CURRENT clinical summary from the physician, please ensure that the summary is translated into English includes the following details. Your Patient Access Coordinator will follow up with you if specific images and tissue/blocks are needed for the review process or at your first visit.

  • Diagnosis: date; stage; metastasis (sites, solitary or multiple locations, liver or lung or LN).
  • History of physical exam (previous all outside MD H&P’s, visit/clinic notes), family history
  • Pathology (at least pathology reports and slides –unstained slides or blocks upon COH MD request) KRAS, RAS (KRAS and NRAS), BRAF mutation testing, MMR/MSI
  • COH MD may order TEGEN panel in some cases
  • Endoscopic test and results, needle biopsy
  • Surgical history& operative notes (size, Lymph node involvement and location of tumor)
  • Chemotherapy or targeted therapy records and reports including
  • All regimens (start & stop date)
  • Number of cycles
  • Chemotherapy “best” response for how long. Indicate if treatment fails and when
  • Last imaging study results, CD’s digital format (CT chest, abdomen and pelvic, PET/CT and/or MRI –include all other diagnostic imaging that were done in the past)
  • Potential COH pathology team to review slides
  • Potential Radiologist to review imaging CDs
  • Laboratory results (CEA, CBC, CMP) and physical condition
  • Inherit genetic conditions: such as Lynch Syndrome, FAP and associated syndromes, MAP, PJS, JPS, P TEN-Hamartoma tumor syndromes, MMR or MSI
  • Current treatment plan
Ovarian, Uterine and Vulva Cancer Patient Evaluation
Basic Text Field

Kindly provide us with these medical records and information (in English), or if you possess a typed CURRENT clinical summary from the physician, please ensure that the summary is translated into English includes the following details. Your Patient Access Coordinator will follow up with you if specific images and tissue/blocks are needed for the review process or at your first visit.

  • Diagnosis: date; stage; metastasis
  • Abdominal/pelvic exam, ultrasound and/or abdominal/pelvic CT/MRI
  • Pathology review
  • CA-125 or other tumor markers
  • Recent lab result (CBC, Chemistry with liver function test)
  • Family history, relevant past H&P
  • Other imagine and scans (chest CT or chest x-ray, GI evaluation)
  • Previous treatments (what were the treatment) and response to treatments
  • Any staging done previously (T), (N), (M)
  • Patient’s current signs, symptoms and current treatment plan
  • HPV testing if done, HIV testing if done
Liver Cancer Patient Evaluation
Basic Text Field

Kindly provide us with these medical records and information (in English), or if you possess a typed CURRENT clinical summary from the physician, please ensure that the summary is translated into English includes the following details. Your Patient Access Coordinator will follow up with you if specific images and tissue/blocks are needed for the review process or at your first visit.

  • Diagnosis: date; stage; metastasis (sites).
  • History of physical exam (previous all outside MD H&P’s, visit/clinic notes), family history, Alcohol consumption, fatty liver or cirrhosis, hepatitis status,
  • Pathology (at least pathology reports and slides, may need more slides or blocks upon COH MD request), FNA biopsy, core biopsy
  • Surgical history& operative notes (size, lymph node involvement)
  • Chemotherapy or targeted therapy records and reports including:
    • All regimens (start & stop date)
    • Number of cycles
    • Chemotherapy “best” response for how long. Indicate if treatment fails and when.
  • Last imaging study results, CD’s digital format (EUS, Ultrasound, CT abdomen & chest, MRI) bone scan if necessary, Laparoscopy
  • Potential COH pathology team to review slides
  • Potential Radiologist to review imaging CDs
  • Laboratory results (Hepatitis panel, Liver Function panel, Bilirubin, transaminases, alkaline phosphatase, PT or INR, albumin, BUN, creatinine, MP, CBC, platelets, AFP)and physical condition
  • Current treatment plan
Gastric - Esophageal Cancer Patient Evaluation
Basic Text Field

Kindly provide us with these medical records and information (in English), or if you possess a typed CURRENT clinical summary from the physician, please ensure that the summary is translated into English includes the following details. Your Patient Access Coordinator will follow up with you if specific images and tissue/blocks are needed for the review process or at your first visit.

  • Diagnosis: date; stage; metastasis
  • History and physical exam (previous all outside MD H&Ps, visit/clinic notes), family history
  • Upper GI endoscopy and biopsy
  • Chest/abdomen/pelvic CT with oral and IV contrast
  • PET/CT evaluation (skull base to mid-thigh) if no evidence of M1 disease and if clinically indicated
  • Recent labs (CBC and CMP)
  • Endoscopic ultrasound, endoscopic resection, biopsy of metastatic disease as clinically indicated
  • MSI-H/dMMR testing if metastatic disease is documented/suspected
  • HER2 and PD-L1 testing if metastatic adenocarcinoma is documented/suspected
  • Smoking history
  • Current treatment plan (chemotherapy or targeted therapy records)
  • Surgical history & operative notes
  • Potential COH pathologist to review slides and COH radiologist to review imaging CDs
Pancreatic Cancer Patient Evaluation
Basic Text Field

Kindly provide us with these medical records and information (in English), or if you possess a typed CURRENT clinical summary from the physician, please ensure that the summary is translated into English includes the following details. Your Patient Access Coordinator will follow up with you if specific images and tissue/blocks are needed for the review process or at your first visit.

  • Diagnosis: date; stage; metastasis (sites).
  • History of physical exam (previous all outside MD H&P’s, visit/clinic notes), family history, Alcohol consumption, fatty liver or cirrhosis, hepatitis status,
  • Pathology (at least pathology reports and slides, may need more slides or blocks upon COH MD request), FNA biopsy, core biopsy
  • Surgical history& operative notes (size, lymph node involvement)
  • Chemotherapy or targeted therapy records and reports including:
    • All regimens (start & stop date)
    • Number of cycles
    • Chemotherapy “best” response for how long. Indicate if treatment fails and when.
  • Last imaging study results, CD’s digital format (EUS, Ultrasound, CT abdomen & chest, MRI) bone scan if necessary, Laparoscopy
  • Potential COH pathology team to review slides
  • Potential Radiologist to review imaging CDs
  • Laboratory results (Hepatitis panel, Liver Function panel, Bilirubin, transaminases, alkaline phosphatase, PT or INR, albumin, BUN, creatinine, MP, CBC, platelets, AFP)and physical condition
  • Current treatment plan
Head and Neck Cancer Patient Evaluation
Basic Text Field

Kindly provide us with these medical records and information (in English), or if you possess a typed CURRENT clinical summary from the physician, please ensure that the summary is translated into English includes the following details. Your Patient Access Coordinator will follow up with you if specific images and tissue/blocks are needed for the review process or at your first visit.

  • H&P including a complete head and neck exam ( + mirror and/or fiberoptic exam if indicated)
  • Diagnosis with date and stage; metastasis
  • Pathology review (primary site or fine needle aspiration)
  • Scans (CT chest w/wo contrast, panorex, CT or MRI of primary, PET/CT)
  • Recent labs
  • Past treatments and Reponses, surgical reports
  • Paranesthesia studies, PFTs if applicable
  • EUA(examination under anesthesia) with endoscopy
  • Dental/prosthetic evaluation, nutrition, speech, and swallowing evaluation as indicated
  • Patient’s current signs, symptoms and current treatment plan
Hematologic Cancer (non-BMT) Patient Evaluation
Basic Text Field

Kindly provide us with these medical records and information (in English), or if you possess a typed CURRENT clinical summary from the physician, please ensure that the summary is translated into English includes the following details. Your Patient Access Coordinator will follow up with you if specific images and tissue/blocks are needed for the review process or at your first visit.

  • Diagnosis: date; stage; metastasis.
  • History of physical exam, family history
  • Pathology at least pathology reports, preferable digital pathology
  • Cytogenetic, Molecular reports, prognostic factors, immunophenotypes or subtype markers, bone marrow hematopathology reports, flow cytometry report
  • Surgical history& operative notes
  • Chemotherapy report including:
    • All regimens (start & stop date)
    • Number of cycles
    • Chemotherapy response. Indicate if treatment fails and when
  • Last imaging study results
  • History of transfusion or trends of CBCs
  • Laboratory results (at least CBC, CMP, LDH) and physical condition
  • Current treatment plan
Soft Tissue Sarcoma Patient Evaluation
Basic Text Field

Kindly provide us with these medical records and information (in English), or if you possess a typed CURRENT clinical summary from the physician, please ensure that the summary is translated into English includes the following details. Your Patient Access Coordinator will follow up with you if specific images and tissue/blocks are needed for the review process or at your first visit.

  • Diagnosis: date; stage; metastasis (sites, solitary or multiple locations)
  • History of Physical Exam (previous all outside MD H&P’s, visit/clinic notes, consult notes)
  • Imaging (CT and MRI w/ contrast, Chest, X-ray, PET/CT, ultrasound)
  • Image guided core needle biopsy (preferred over surgical biopsy)
  • Surgical History & operative notes
  • Chemotherapy (# of cycles, regiments, response)
  • Chemoradiation, RT, Regional limb therapy, SBRT
  • Laboratory results

 

 

Contact Us
If you have further questions, please contact us