• A diagnosis of incurable cancer with documentation to support the diagnosis.

(A pathological report, CT scan or similar documentation is required.)

 

• The need for palliative care after all aggressive cancer treatment(s)

[i.e. radiation, chemotherapy and surgery] have been completed.

 

• Financial need: Insurance is not accepted, but those with insurance are not automatically disqualified; individual circumstances are taken into consideration.

 

• A signed Do Not Resuscitate form (DNR).

 

• TB QuantiFERON Test Results.

 

• A list of current medications.

 

• A signed Health Care Proxy.

 

• A completed NY DOH 695 screening form (if New York resident).

 

• A medical history and physical exam or consultation (i.e., narrative report).

 

• A completed APPLICATION FORM (please complete all five pages).

 

• TB Treatment Agreement Form, if applicable.