HCP Referral Inquiry

Referral Inquiry by Medical/Health Care Professional Form

INSTRUCTIONS: The Zeuner Foundation grants requests for charitable wishes to adults age 18 and over who are either (1) diagnosed with terminal cancer or (2) caregivers of adults diagnosed with terminal cancer. In order to refer an individual to the Zeuner Foundation, this form must be completed and signed by an authorized health care professional* who has direct knowledge of the medical condition of an adult with a terminal cancer diagnosis. This form should only be submitted to the Zeuner Foundation after the authorized health care professional has permission from the terminally ill adult to make this referral.

This inquiry form is the first step in the Zeuner Foundation’s Charitable Wish Granting Process. It is not confirmation of eligibility for a wish (i.e., submitting a completed form is not confirmation that the referred individual is eligible to receive a wish). The information you provide will be shared with the Zeuner Foundation’s Wish Granting Team and you will be contacted by a member of the team about your referral.

Patient Information:

Name of Adult with Terminal Cancer *(*)

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Patient's Date of Birth(*)

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Patient’s legal representative, if applicable *(*)

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Name of Referred Individual/Intended Wish Recipient (Patient or Patient’s Caregiver) *:(*)

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Your Name *(*)

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Your Email *(*)

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Your Phone Number *(*)

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Please indicate whether the Patient has a qualifying condition by checking the box below:

Condition(*)

PATIENT HAS A QUALIFYING CONDITION (TERMINAL CANCER DIAGNOSIS), AS OF THE DATE BELOW. I am familiar with the Patient’s medical condition and certify that, as of the date below for this referral, the Patient has been diagnosed with a life-threatening cancer condition (i.e., a medical condition that has currently placed the individual’s life in jeopardy). Please explain condition below. (Note: The Zeuner Foundation may contact you if there are any questions regarding the Patient’s diagnosis/medical condition or a need for additional information.)

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Permission To Make Referral(*)

I spoke with the Patient about making this referral and have his or her permission to make this referral (i.e., submit this completed Referral Inquiry by Medical/Health Care Professional Form). For example, Patient completed a HIPAA-Compliant Authorization that authorized you to share his or her information with the Zeuner Foundation.

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Patient’s qualifying condition (terminal cancer diagnosis) *(*)

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The qualifying medical condition is currently life-threatening and

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Type I'm.Not.A.Robot replacing the periods with spaces(*)

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