Services
Previvorsandsurvivors.com, Inc.
criteria for services: LIVE IN LONG ISLAND, NY; BRCA positive & as a result: mastectomy or oophorectomy.
Request for services: hair, food, car service.
Step 1:
Please email all requests stating specifically what services you will require to: tobeyrdh@previvorsandsurvivors.com
You will then be asked to fill out the following forms below & fax them back to us.
At this time, because of limited funds, our services will be limited to a first come first serve basis and the services will not exceed more than $300.00 per family.
Please have your physician fill out the medical clearance & you & your physician will have to fill out the HIPPA form and fax it to: 516-766-1604 or email all to: tobeyrdh@previvorsandsurvivors.com
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Step 2:
previvorsandsurvivors.com, Inc.
Medical Clearance
Patient’s Name:________________________________________________________________
Patient’s Address:_______________________________________________________________
Patient’s phone number:_________________________________________________________
Patient’s surgical procedure & dates of procedure:____________________________________
______________________________________________________________________________
Patient’s expected date to resume daily activities:____________________________________
Family members living in household:_______________________________________________
Is patient well enough to have a volunteer come in to wash/dry hair without any complications expected? ______________________________________________________________________________
Food restrictions:_______________________________________________________________
Is patient well enough for car services?______________________________________________________________________
Physician Name:__________________________ Physician Phone:____________________
Physician’s address:_____________________________________________________________
Physician Signature :____________________________________ Date:____________
Comments:
___________________________________________________________________________________
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Step 3:
the official OCA Form No.: 960 can be printed this link:
http://www.courts.state.ny.us/forms/Hipaa_fillable.pdf
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Step 4:
previvorsandsurvivors.com, Inc.
person requesting services needs to fill this out & fax to: 516-766-1604
Release and Waiver of Liability Form
I, ___________________________________________ today’s date:_____________________
Request the services of previvorsandsurvivors.com, Inc. I understand that this group is a not for profit group and I am not required to compensate anyone from previvorsandsurvivors.com for their services provided.
I understand that in the event of personal injury as a result of the services, I discharge and release previvorsandsurvivors.com, Inc. from any and all liability, claims and demands of whatever kind or nature, either in law or in equity, which arise after the services I receive.
Name:________________________________________________________________________
Address:______________________________________________________________________
_____________________________________________________________________________
Phone:_______________________________________________________________________
Signature: ______________________________________ Date:_______________________
Comments:
______________________________________________________________________________