Dear Office of Constituent:
Thank you for contacting the Office of Government/Community Affairs at The James regarding
your constituent matter. In order to expedite your request, we ask for additional information and
specific contact information (see attached form).
You may send the completed casework form by e-mail, cancer.advocacy@osumc.edu, or fax
(614) 366-1524.
According to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy
and Security Rules, we are required to protect the confidentiality of our patient. We will try to
the best of our ability to keep your office updated on your constituent matter, however, please
understand that maintaining appropriate confidently for the patient is our foremost priority.
Should you have questions about this process, please do not hesitate to contact us.
Best Regards,
Stefanie Freeman
Program Coordinator for Government Affairs
James Cancer Hospital & Solove Research Institute
660 Ackerman Rd.
5th Floor Cube #8
Columbus, OH 43202
Phone: (614) 293.3994
Fax: (614) 366.1524
Mailing Address:
PO Box 183109
Columbus, OH 43218-3109
Enc. Casework Form
CASEWORK FORM
PART I – PERSONAL INFORMATION
Full Name:
Gender:
Last 4 digits of Social Security Number:
Date of Birth: MM/DD/YYYY
USA Citizen?
Yes
Permanent Resident?
No
Yes
If No, Country of Citizenship:
No
If Yes, A#:
Home Address:
Home Phone:
City, State, Zip:
Other Phone:
Email:
Fax:
Emergency Contact Name:
Relation:
Contact Phone:
FOR PATIENT INFORMATION ONLY (This section is optional.)
Health Insurance Carrier:
Subscriber Name:
Member Number:
Group Number:
Group Name:
Insurance Phone:
PART II – REQUESTOR INFORMATION
Requestor:
Office Address:
Office Phone:
Office Fax:
Request:
Part III – FOR GOVERNMENT/COMMUNITY AFFAIRS DEPARTMENT USE ONLY
Case Reviewed by:
Date Opened: MM/DD/YYYY
Date Closed: MM/DD/YYYY
Action Steps:
2
Female
Male