The Dr. Harold P. Freeman Institute
Patient Navigation Certification Application
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Name:
Title:
Facility:
Gender:
Male
Female
Current Address:
City:
State:
Zip:
Tel:
Fax:
Mobile:
Email:
Education:
High School
Collage
Graduate
Post-Grad
Facility
Private
Public
Type
Profit
Non-Profit
Address:
Same as Above
Program Address:
City:
State:
Zip:
Year Founded
Staff Composition (#):
Population Served (#):
Annual Visits of:
FTE:
...
Popoulation Ethnicity (%)
White:
Black:
Latino:
Other:
...
Volunteers:
...
Insurance Coverage (%)
Private:
Public:
Self-Pay
...
How would you rate the guest/patient experience at your facility?
Choose One:
Poor
Fair
Good
Excellent
Funding Sources
Avon
Leukemia & Lymphoma Society
Susan G. Koman
Do you currently have a Patient Navigation Program?
Yes
No
If so, when was the program established?
How many (FTE) Patient Navigators:
Have Navigators recieved prior formal training?
Yes
No
When:
Where:
Have you previously applied to the HPF PN Institute?
Yes
No
Scheduling
Anticipated Training Month:
January
February
March
April
May
June
July
August
September
October
November
December
Contact Info:
Same as Above
Contact Person
Contact e-mail:
Contact Phone:
Contact Fax:
Contact Address:
Contact City:
Contact State:
Contact Zip:
Referrals
Referral 1
Name and Title
Organization
Address
City, State, Zip
Phone
...
Referral 2
Name and Title
Organization
Address
City, State, Zip
Phone
...
Referral 3
Name and Title
Organization
Address
City, State, Zip
Phone
Are you Ready to Submit Application
Please Re-Type your name:
Enter Date of Application: