Patient Review Checklist_Hero

Patient Review Checklist

Below is a comprehensive list of the essential forms and documentation required to initiate the review process. Please note that all medical records must be submitted in English, including the patient's full name and date of birth, which must match the information on the patient’s official ID. In cases where medical documents are not originally in English, please ensure they are translated by a certified medical translator. Unfortunately, we cannot proceed with the review or referral without the necessary medical records. It is crucial that all medical records, images, and tissue samples/blocks include the exact full name and date of birth as shown on the official ID. Our medical team may also request specific tests or evaluations to be conducted prior to your visit to City of Hope®. To submit your medical records, please email them to [email protected].
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FAQ
If you have a typed CURRENT clinical summary from your physician, please ensure that it 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)
•  All molecular testing reports
•  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)

Additionally, each type of cancer may require specific information to ensure a comprehensive review. To assist you in gathering the necessary details, we have developed customized checklists for various cancer types. These checklists will guide you in providing the essential information needed both for the review process and your initial visit. Please select the appropriate checklist based on the specific type of cancer for which you are seeking evaluation from the list below. Should further specific images or tissue samples/blocks be required, your Patient Access Coordinator will contact you to coordinate the necessary preparations for your review process or initial visit.

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 and 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 M.D. History and Physical, visit/clinic notes), family history, smoking history
• Pathology (at least pathology reports and slides, may need more slides or blocks upon City of Hope M.D. request)
• Cytogenetic, molecular reports, prognostic factors, immunophenotypes or subtype markers, biomarker (EGRF mutation both either blood sample or tissue sample, ALK gene rearrangement, ROS1 gene may be needed for patient with normal or unknown EGFR or ALK status, PD-L1 expression, BRAF V600E mutation, High-level MET amplification, RET gene rearrangements and HER2 mutations), proteomic test, flow cytometry report
Surgical history and operative notes (size and location of tumor)
Chemotherapy or targeted therapy records and reports including:
   • All regimens (start and stop date)
   • Number of cycles
   • Chemotherapy response. Indicate if treatment fails and when
   • Current treatment plan
• Last imaging study results, CD’s digital format (computed tomography (CT) chest and upper abdomen and adrenals, positron emission tomography (PET)/CT scan, brain magnetic resonance imaging (MRI))
• Potential City of Hope 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 mediastinal lymph node evaluation reports, or biopsy
• Laboratory results (at least complete blood count (CBC), comprehensive metabolic panel (CMP)) and physical condition

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 and 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 magnetic resonance imaging (MRI) date and 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 results or additional labs needed
• Other imaging and scans (chest X-ray, bone scan, computed tomography (CT) scan of abdomen, positron emission tomography (PET) scan, MRI brain scan)
• Past treatments (what the treatments were) and response treatments
• Any staging done previously (T), (N), (M)
• Family history, relevant past History and Physical
• Patient’s current signs, symptoms and current treatment plan

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 and 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 M.D. History and Physical, visit/clinic notes), family history, life expectancy estimation
• Pathology (prostate biopsy, at least pathology reports and slides, may need more slides or blocks upon City of Hope M.D. request)
• Digital rectal examination (DRE) report
• Prostate-specific antigen (PSA) level
• Surgical history and 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 (computed tomography (CT) chest and upper abdomen and adrenals, positron emission tomography (PET)/CT scan, brain magnetic resonance imaging (MRI))
• Potential City of Hope 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 mediastinal lymph node evaluation reports or biopsy
• Laboratory results (at least complete blood count (CBC), comprehensive metabolic panel (CMP), PSA) and physical condition

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 and 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 lymph node)
• History of physical exam (previous all outside M.D. History and Physical, visit/clinic notes), family history
• Pathology (at least pathology reports and slides — unstained slides or blocks upon City of Hope M.D. request) KRAS, RAS (KRAS and NRAS), BRAF mutation testing, MMR/MSI
• City of Hope M.D. may order the Translational Genomics Research Institute (TGen) 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

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 and 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 M.D. History and Physicals, 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 City of Hope M.D. request), fine needle aspiration (FNA) biopsy, core biopsy
• Surgical history and operative notes (size, lymph node involvement)
• Chemotherapy or targeted therapy records and reports including:
   • All regimens (start and 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 (endoscopic ultrasound (EUS), ultrasound, computed tomography (CT) abdomen and chest, magnetic resonance imaging (MRI) bone scan if necessary, laparoscopy
• Potential City of Hope 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

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 and 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 M.D. History and Physicals, visit/clinic notes), family history
• Upper gastrointestinal endoscopy and biopsy
• Chest/abdomen/pelvic computed tomography (CT) with oral and IV contrast
• Positron emission tomography (PET)/CT evaluation (skull base to mid-thigh) if no evidence of M1 disease and if clinically indicated
• Recent labs (complete blood count (CBC) and comprehensive metabolic panel (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 and operative notes
• Potential City of Hope pathologist to review slides and City of Hope radiologist to review imaging CDs

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 and 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 M.D. History and Physicals, 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 City of Hope M.D. request), fine needle aspiration (FNA) biopsy, core biopsy
• Surgical history and operative notes (size, lymph node involvement)
• Chemotherapy or targeted therapy records and reports including:
   • All regimens (start and 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 (endoscopic ultrasound (EUS), ultrasound, computed tomography (CT) abdomen and chest, magnetic resonance imaging (MRI) bone scan if necessary, Laparoscopy
• Potential City of Hope 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

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 and 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.

• Health and Physical, 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 (FNA))
• Scans (computed tomography (CT) chest with/without contrast, panorex, CT or magnetic resonance imaging (MRI) of primary, positron emission tomography (PET)/CT)
• Recent labs
• Past treatments and responses, surgical reports
• Paranesthesia studies, pulmonary function tests (PFT) 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

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 and 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, preferably digital pathology
• Cytogenetic, molecular reports, prognostic factors, immunophenotypes or subtype markers, bone marrow hematopathology reports, flow cytometry report
• Surgical history and operative notes
• Chemotherapy report including:
   • All regimens (start and stop date)
   • Number of cycles
   • Chemotherapy response. Indicate if treatment fails and when
• Last imaging study results
• History of transfusion or trends of complete blood counts (CBC)
• Laboratory results (at least CBC, comprehensive metabolic panel (CMP), LDH) and physical condition
• Current treatment plan

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 and 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 M.D. History and Physicals, visit/clinic notes, consult notes)
• Imaging (computed tomography (CT) and magnetic resonance imaging (MRI) with contrast, Chest, X-ray, positron emission tomography (PET)/CT, ultrasound)
• Image-guided core needle biopsy (preferred over surgical biopsy)
• Surgical history and operative notes
• Chemotherapy (number of cycles, regiments, response)
• Chemoradiation, radiotherapy (RT), regional limb therapy, stereotactic body radiotherapy (SBRT)
• Laboratory results

For urgent assistance or inquiries, please contact us directly at +1 (833) 330-4673 or via email at [email protected]. Our team is prepared to listen, understand your unique situation, and provide the necessary support. 

 

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