Advocacy o Medical system Accompany client to medical appointment Outreach/recruit clients into/for health screening. Navigation: Breast health only
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1 Donna Banks Good Samaritan Hospital th Ave SE Puyallup WA PH: (253) FX: (253) Accompany client to medical Breast health only African American Hispanic/Latino Pacific Islander American Indian/Alaskan Native Asian Stella Bartose Accompany client to medical Assist client with charity care Pacific Islander Tongan Patty Berke, MSW Oncology Clinic Madigan Army Medical Center Tacoma WA PH: (253) FX: (253) Accompany client to medical charity care o Military-related population eligible for care at Madigan African American Hispanic/Latino Pacific Islander American Indian/Alaskan Native Asian 1/4/2011 Tacoma-Pierce County Health Department Page 1 of 10
2 Michelle Donaldson, RN Multicare Health Systems SE 272 nd M/S BHS Covington WA PH: (253) FX: (253) charity care Breast health only African American Hispanic/Latino Pacific Islander American Indian/Alaskan Native Asian Russian Ukrainian Falelua Edwards Pacific Islander Samoan Jess Fanene charity care Pacific Islander Samoan 1/4/2011 Tacoma-Pierce County Health Department Page 2 of 10
3 Soon J Han Korean Women s Association 123 E 96 th St Tacoma WA sjhankwa@nwlink.com PH: (253) FX: (253) Breast health only Breast & Cervical Health Program Asian Korean Korean Bona Khim KWA-ICSC 1427 E 40 th St bkhimkwa@nwlink.com PH: (253) FX: (253) Asian Cambodian Vietnamese Breast health only Cambodian Vietnamese 1/4/2011 Tacoma-Pierce County Health Department Page 3 of 10
4 Korean Women s Association 123 E 96 th St Tacoma WA PH: FX: Breast health only o Community resources Hispanic/Latino Spanish English Jackie LeSage Accompany client to medical charity care Pacific Islander Chamorro English 1/4/2011 Tacoma-Pierce County Health Department Page 4 of 10
5 Nicole McKay American Cancer Society 1717 S J St Tacoma WA Nicole.mckay@cancer.org PH: (253) FX: (253) charity care African American Hispanic/Latino Pacific Islander American Indian/Alaskan Native Asian o Korean o Cambodian o Filipino o Thai o Lao Russian Ukrainian Aiaga Nichols charity care Pacific Islander Samoan 1/4/2011 Tacoma-Pierce County Health Department Page 5 of 10
6 Susan Nixon, RN, BSN, OCN Franciscan Health System 1617 S J St Tacoma WA susannixon@fhshealth.org PH: (253) FX: (253) African American Hispanic/Latino Pacific Islander American Indian/Alaskan Native Asian o Korean o Cambodian o Filipino o Vietnamese o Thai Breast health only Korean Spanish Cambodian Vietnamese Thai Lao Russian Ukrainian Tagalog Samoan Lao Russian Ukrainian Melodie Petersen Providence Regional Cancer System 3417 Ensign Road NE Olympia WA PH: (360) FX: (360) charity care African American Hispanic/Latino Pacific Islander American Indian/Alaskan Native Asian Russian Ukranian Breast health only Interpreters arranged as needed 1/4/2011 Tacoma-Pierce County Health Department Page 6 of 10
7 Mary Quinene Assist client with charity care Pacific Islander o Chamorro Chamorro Samoa Guam Tongan Claudia Rodriguez Community Health Care Gravelly Lake Dr SW Lakewood WA crodriguez@commhealth.org PH: (253) FX: (253) charity care Hispanic/Latino Spanish 1/4/2011 Tacoma-Pierce County Health Department Page 7 of 10
8 Bobbi Salmond Community Health Care 1102 S I St Tacoma WA bsalmond@commhealth.org PH: (253) FX: (253) charity care African American Hispanic/Latino Pacific Islander American Indian/Alaskan Native Asian o Cambodian o Korean o Filipino o Vietnamese o Thai o Lao Russian Ukrainian Korean Spanish Vietnamese Russian Ukrainian Deana Trammell charity care Pacific Islander Other English 1/4/2011 Tacoma-Pierce County Health Department Page 8 of 10
9 Moana Trammell Accompany client to medical charity care Pacific Islander Samoan English Jessica Wagner Harrison Medical Center 2520 Cherry Ave Bremerton WA PH: (360) FX: (360) African American Hispanic/Latino Pacific Islander American Indian/Alaskan Native Asian Russian Ukrainian Sue Yamane Northwest Medical Specialties 1624 S I St Tacoma WA syamane@nwmsonline.com PH: (253) FX: (253) charity care African American Hispanic/Latino Pacific Islander American Indian/Alaskan Native Asian Russian Ukrainian Interpreters arranged as needed 1/4/2011 Tacoma-Pierce County Health Department Page 9 of 10
10 Marilyn Levinsohn/Elizabeth Ulrich/Denise Cole Breast Cancer Resource Center 3502 S 12 th St, Ste A Tacoma WA PH: (253) FX: (253) o Support services finding financial assistance Patient Assistance Fund application African American Hispanic/Latino Pacific Islander American Indian/Alaskan Native Asian o Cambodian o Korean o Filipino o Vietnamese o Thai o Lao Russian Ukrainian Breast health only Spanish 1/4/2011 Tacoma-Pierce County Health Department Page 10 of 10
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CIT-06 Eligibility Questionnaire
Today s Date: Last Name: First Name: Middle Name: Date of Birth: Height: Weight (lbs): PERSONAL CONTACT INFORMATION Street Address: City: State: Zip code: Home Phone: Cell Phone: Work Phone: Email Address: