Community Scholars Social Determinants of Health Request Form

For physician/administrator use only.

Community Scholars physicians can request additional services for patients who are already in the Community Scholars program. Please complete the fields below for this request.

We will get back to you within 3-4 business days with next steps for processing your request.
If you have additional questions, please send us an email.

*denotes required field

Physician Information

Scholar’s physician first name * Scholar’s physician last name * Scholar’s physician’s specialty *

Patient Information

Please enter patient’s name exactly as shown on official identification. Patient first name * Patient last name * Patient date of birth * Patient’s Houston Methodist MRN *

Additional Services Requesting

Note: Home Health and Breast Prosthesis services are only available for Oncology. Please check the areas you are requesting service * Transportation Medical Equipment for mobile assistance Food Assistance Home Health Services (available for Oncology only) Breast Prosthesis (through HMSL; available for Oncology only)

Please specify what medical equipment is needed for mobile assistance *

Diagnosis date * Breast cancer site * Left Right Both Cancer treatment facility * Date chemotherapy was completed Date radiation was completed Surgical date Will the patient be having reconstructive surgery? Yes No If yes, when will the reconstructive surgery take place?

Notes/Comments regarding your request Requestor First Name * Requestor Last Name * Requestor Email address *

Authentication *

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Community Scholars Social Determinants of Health Request Form

Physician Information

Patient Information

Additional Services Requesting

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