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Effective Date: 
6/2016

Documents


Instructions

Update: 4/2013

PURPOSE

To serve as a verification that a woman is actively receiving treatment for breast and/or cervical cancer.

PROCEDURE

When to Prepare

At her periodic review (or if the client's active treatment is questionable), the client will present the form to her physician to complete. The physician indicates if the client is actively receiving treatment for breast or cervical cancer.  Active cancer treatment includes services related to the individual’s condition as documented in her plan of care, such as:

  • Surgery;
  • Chemotherapy;
  • Radiation;
  • Reconstructive surgery; and
  • Medication (ongoing hormonal treatment).

These services may also include diagnostic services that are necessary to determine the extent and proper course of treatment and active disease surveillance for triple negative receptor breast cancer.

Form Retention

See the Manager's Guide for Eligibility Programs.

DETAILED INSTRUCTIONS

The client's name, mailing address, date, advisor's name, case number and EDG number are all completed by HHSC staff. The remainder of the form is completed by the client's physician or other medical practitioner familiar with the client's care. A medical practitioner is an individual who holds a license to practice medicine: physician (MD), osteopathic medical physician (DO), dentist (DDS), advance nurse practitioner (ANP) or registered nurse (RN). Note: A licensed practical nurse (LPN), a licensed vocational nurse (LVN) or a midwife does not meet the definition of practitioner. To evaluate specific answers, refer to policies in the Texas Works Handbook.

The advisor will also enter the patient's name in the space giving her permission for release of the requested information. The client signs and dates the form in the spaces provided.