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Single Specialty Practice Application

Page One

Thank you for your interest in listing your practice on the Cutaneous Lymphoma Foundation's website. Practices with one specialty will be designated as a "practice that has an expertise in treating cutaneous lymphoma" on the Treatment Center directory. (The "multidisciplinary center" designation applies to those centers where more than one medical specialty collaborates in the care of patients with cutaneous lymphoma.)

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.

Name of Practice *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.

2. General Information

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

3. 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

4. Contact Person to Verify Information - who is best person to contact for updates *This question is required.

First Name

Last Name

Title

Email Address

Phone Number

Additional Information to Provide

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

File: {{filename}} delete

5. The Cutaneous Lymphoma Foundation urges clinicians to be a member of one (or more) of the following professional associations. Please 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.

6. 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

Composition

Our goal is to offer a multidisciplinary team to provide the best comprehensive care possible to individuals with cutaneous lymphoma. If a patient's needs fall outside the scope of the services your practice offers, who do you refer them to?

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.

7. Multidisciplinary Services

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:

8. 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)

9. 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

10. Services (Check all that apply)

11. 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
Interferon	Interferon: Delivered On Site	Interferon: Referred to Collaborating Specialist/Center	Interferon: 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
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
Enter another option	Other: Delivered On Site	Other: Referred to Collaborating Specialist/Center	Other: N/A
Enter another option	Other: Delivered On Site	Other: Referred to Collaborating Specialist/Center	Other: N/A
Enter another option	Other: Delivered On Site	Other: Referred to Collaborating Specialist/Center	Other: N/A

12. Research Program (check all that apply)

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

Additional Services Provided (check all that apply):

Programs for international patients
Nutrition
Other (Please list) Please enter an 'other' value for this selection.

13. Approximate number of new CTCL patient visits per year? This question requires a valid number format.

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

By submitting your practice'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.