Woman to Woman Patient Application
Thank you for your interest in Woman to Woman (W2W), a partnership program between the Ovarian Cancer Research Alliance, Sue's Gift and your medical team. The Woman to Woman program matches women with a gynecologic cancer diagnosis with someone who has completed treatment. The knowledge and insight of a survivor who had the same diagnosis and similar experience can alleviate feelings of isolation and the unknown.
To facilitate the best possible match, please complete the following information. We will be in touch with you once we receive this form to set up a brief 1:1 program overview prior to matching you with a survivor.
Additional information to assist with facilitating the best match:
To ensure privacy protection as part of the Health Insurance Portability and Accountability Act (HIPAA) and to provide indivicuals with control over what personal information is used and disclosed, I agree to provide the above information to Sue's Gift.
Please contact Sherry Martin, LCSW, Patient Services Director, at 719-422-9964 or firstname.lastname@example.org.
If you are a healthcare professional submitting this information on behalf of a patient, please complete the following: