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Treatment Center Directory Application

Page One

Thank you for your interest in listing your medical center as a multidisciplinary cutaneous lymphoma treatment center on the Cutaneous Lymphoma Foundation's website. The "multidisciplinary center" designation will apply to those centers where more than one medical specialty collaborates in the care of patients with cutaneous lymphoma. (For those practices with one specialty, please use the Single Specialty Facility Application)

By completing and submitting the application form, you agree to update your information annually and to provide patients with the Cutaneous Lymphoma Foundation's educational materials either directly or via website referral.

1. Submission Date This question requires a valid date format of MM/DD/YYYY.

calendar

3. Please check this box if you are a medical professional working within a larger multidisciplinary clinic but are only filling out a portion of this form as it relates to your particular discipline.

Only filling out portion for my discipline area

Please list the names of additional medical professionals who will be contributing to this form at a later time so that we can ensure they are contacted prior to your center’s posting. Please include contact email or phone number if known.

Name of Center *This question is required.

Upon reviewing information provided on your website, please select which statement is true for your facility.
Please note: you will be required to provide current "who to contact for updates" information regardless of selection.

4. General Information

Name of Center
Street Address
Address
City
State/Province
Postal Code
Country
General Office Email
General Office Phone Number
Phone Number for Appointments
Website link

5. General Contacts

	First Name	Last Name	Email	Phone
	First Name	Last Name	Email	Phone	Office Manager	First Name	Last Name	Email	Phone
Referral Contact	First Name	Last Name	Email	Phone

6. Who can we contact should there be questions with your submission or application? *This question is required.

First Name

Last Name

Title

Email Address

Phone Number

7. Who is the best person to contact for yearly review and updates if different than contact above?

	First Name	Last Name	Email	Phone
	First Name	Last Name	Email	Phone	Contact	First Name	Last Name	Email	Phone

Additional Information to Provide

Please upload a copy of lead cutaneous lymphoma physician's CV. *This question is required.

File: {{filename}} delete

8. Professional Affiliations (Check all that apply)

American Academy of Dermatology
American Society of Hematology
American Society of Clinical Oncology
International Society of Cutaneous Lymphoma
United States Cutaneous Lymphoma Consortium
Other (Please List) Please enter an 'other' value for this selection.

9. Please upload a copy of any cutaneous lymphoma patient and/or marketing materials that are distributed from your office or center; please include any language and/or materials posted on your website.

File: {{filename}} delete

10. Photo Image of Treatment Center (Optional)

File: {{filename}} delete

Composition

Please check all that apply and provide names and credentials of providers for each category in the appropriate space below.
If you do not offer a particular service, please supply name(s) of the practices(s) or physicians(s) to which you refer patients.

11. Multidisciplinary Services Offered

Space Cell	Delivered On Site	Referred to Collaborating Specialist/Center	N/A
Dermatological Oncology	Dermatological Oncology: Delivered On Site	Dermatological Oncology: Referred to Collaborating Specialist/Center	Dermatological Oncology: N/A
Medical Oncology	Medical Oncology: Delivered On Site	Medical Oncology: Referred to Collaborating Specialist/Center	Medical Oncology: N/A
Radiation Oncology	Radiation Oncology: Delivered On Site	Radiation Oncology: Referred to Collaborating Specialist/Center	Radiation Oncology: N/A
Dermatopathology	Dermatopathology: Delivered On Site	Dermatopathology: Referred to Collaborating Specialist/Center	Dermatopathology: N/A
Integrative Medicine (Naturopathic Doctor)	Integrative Medicine (Naturopathic Doctor): Delivered On Site	Integrative Medicine (Naturopathic Doctor): Referred to Collaborating Specialist/Center	Integrative Medicine (Naturopathic Doctor): N/A
Nursing	Nursing: Delivered On Site	Nursing: Referred to Collaborating Specialist/Center	Nursing: N/A
Social Work	Social Work: Delivered On Site	Social Work: Referred to Collaborating Specialist/Center	Social Work: N/A
Enter another option	Other: Delivered On Site	Other: Referred to Collaborating Specialist/Center	Other: N/A

Clinicians and Staff

Please list any clinicians or staff currently listed that should be removed:

12. Please provide the names, professional suffixes and specialty for clinicians and staff seeing cutaneous lymphoma patients.

	Onsite	Referred	Specialty	First Name	Last Name	Professional Suffix	Email (for CLF internal use only)
	Location		Specialty	First Name	Last Name	Professional Suffix	Email (for CLF internal use only)
1	1: Location: Onsite	1: Location: Referred	Specialty	First Name	Last Name	Professional Suffix	Email (for CLF internal use only)
2	2: Location: Onsite	2: Location: Referred	Specialty	First Name	Last Name	Professional Suffix	Email (for CLF internal use only)
3	3: Location: Onsite	3: Location: Referred	Specialty	First Name	Last Name	Professional Suffix	Email (for CLF internal use only)
4	4: Location: Onsite	4: Location: Referred	Specialty	First Name	Last Name	Professional Suffix	Email (for CLF internal use only)
5	5: Location: Onsite	5: Location: Referred	Specialty	First Name	Last Name	Professional Suffix	Email (for CLF internal use only)
6	6: Location: Onsite	6: Location: Referred	Specialty	First Name	Last Name	Professional Suffix	Email (for CLF internal use only)
7	7: Location: Onsite	7: Location: Referred	Specialty	First Name	Last Name	Professional Suffix	Email (for CLF internal use only)
8	8: Location: Onsite	8: Location: Referred	Specialty	First Name	Last Name	Professional Suffix	Email (for CLF internal use only)
9	9: Location: Onsite	9: Location: Referred	Specialty	First Name	Last Name	Professional Suffix	Email (for CLF internal use only)
10	10: Location: Onsite	10: Location: Referred	Specialty	First Name	Last Name	Professional Suffix	Email (for CLF internal use only)
11	11: Location: Onsite	11: Location: Referred	Specialty	First Name	Last Name	Professional Suffix	Email (for CLF internal use only)
12	12: Location: Onsite	12: Location: Referred	Specialty	First Name	Last Name	Professional Suffix	Email (for CLF internal use only)
13	13: Location: Onsite	13: Location: Referred	Specialty	First Name	Last Name	Professional Suffix	Email (for CLF internal use only)
14	14: Location: Onsite	14: Location: Referred	Specialty	First Name	Last Name	Professional Suffix	Email (for CLF internal use only)
15	15: Location: Onsite	15: Location: Referred	Specialty	First Name	Last Name	Professional Suffix	Email (for CLF internal use only)

13. New Patients - please check any requirements needed before accepting a new patient

Patient needs a referral from dermatologist or primary care physician
Patient must already have a cutaneous lymphoma diagnosis

14. Services (Check all that apply)

15. Therapies (Check all that apply.)

Space Cell	Delivered On Site	Referred to Collaborating Specialist/Center	N/A
Cutaneous Lymphoma Specific - Skin and Systemic Therapies	Cutaneous Lymphoma Specific - Skin and Systemic Therapies : Delivered On Site	Cutaneous Lymphoma Specific - Skin and Systemic Therapies : Referred to Collaborating Specialist/Center	Cutaneous Lymphoma Specific - Skin and Systemic Therapies : N/A
Phototherapy	Phototherapy: Delivered On Site	Phototherapy: Referred to Collaborating Specialist/Center	Phototherapy: N/A
Local Electron Beam Radiation Therapy	Local Electron Beam Radiation Therapy: Delivered On Site	Local Electron Beam Radiation Therapy: Referred to Collaborating Specialist/Center	Local Electron Beam Radiation Therapy: N/A
Total Skin Electron Beam Radiation Therapy	Total Skin Electron Beam Radiation Therapy: Delivered On Site	Total Skin Electron Beam Radiation Therapy: Referred to Collaborating Specialist/Center	Total Skin Electron Beam Radiation Therapy: N/A
Infusion/Injected Therapies (chemo, targeted, immunotherapy)	Infusion/Injected Therapies (chemo, targeted, immunotherapy): Delivered On Site	Infusion/Injected Therapies (chemo, targeted, immunotherapy): Referred to Collaborating Specialist/Center	Infusion/Injected Therapies (chemo, targeted, immunotherapy): N/A
Interferon	Interferon: Delivered On Site	Interferon: Referred to Collaborating Specialist/Center	Interferon: N/A
Photopheresis	Photopheresis: Delivered On Site	Photopheresis: Referred to Collaborating Specialist/Center	Photopheresis: N/A
Brachytherapy	Brachytherapy: Delivered On Site	Brachytherapy: Referred to Collaborating Specialist/Center	Brachytherapy: N/A

16. Collaborating Treatment Facilities for Referrals

	Therapy Type	Name of Referred Facility
	Therapy Type	Name of Referred Facility	1	Therapy Type	Name of Referred Facility
2	Therapy Type	Name of Referred Facility
3	Therapy Type	Name of Referred Facility
4	Therapy Type	Name of Referred Facility
5	Therapy Type	Name of Referred Facility
6	Therapy Type	Name of Referred Facility

17. Research Program (check all that apply)

Basic Research
Therapeutic Trials
Database/Registry
Other Please enter an 'other' value for this selection.

18. Approximate number of new cutaneous lymphoma patient visits per year? This question requires a valid number format.

19. Approximate number of follow-up cutaneous lymphoma patient visits per year? This question requires a valid number format.

By submitting your center's application, you agree to update your provider roster, contact information, and spectrum of services on an annual basis. Updates may be conducted by interview with the CLF staff or electronically. Failure to update may jeopardize ongoing site listing.

Centers listed on the Cutaneous Lymphoma Foundation's website agree to provide patients with CLF educational materials directly or via website referral.