CareLink - Intake form - Kidney Cancer Association

CareLink Partner Administrator

Institution Overview

Key Contacts for Kidney Cancer / GU Oncology

On-site Clinical Specialties & Services Offered

Kidney Cancer Types & Expertise (Check all that apply)

Kidney Cancer Volume & Expertise

Special Programs & Recognition

On-site Patient Resources & Support Services (Check all that apply)

Insurance

Open Clinical Trials (Kidney Cancer Focus Only)

CareLink Participation Preferences

Optional KCA Program Engagement Opportunities

Additional Comments or Notes

This person will serve as the primary liaison for the institution and can connect KCA to the appropriate contacts, including benefits associated with becoming a CareLink partner.

Name*

Title*

Phone*

Email*

Institution Name*

Program Name (if different)

Logo Upload (Attach file)

Max. file size: 2 GB.

Recommended: SVG, PNG, or high-res JPG.

Street*

City*

State*

ZIP Code*

Appointment Scheduling Phone Number*

Institution Website*

Kidney Cancer Program Website (if different)

Satellite Locations (Name & Address)

Location Name	Street	City	State	ZIP

Add multiple satellite locations; one row per location.

Email addresses will remain internal to KCA and will not appear publicly.

Key Contacts

Add key contacts for your institution. Click “Add Row” to add additional contacts.

Display Key Contacts on the CareLink profile?

Yes
No

Select “No” to hide the Key Contacts section from the public profile.

Appointment Scheduling — Email

Appointment Scheduling — Phone

Clinical Trials Contact — Email

Clinical Trials Contact — Phone

Specialties

Medical Oncology
Urologic Surgery
Radiation Oncology
Interventional Radiology
Radiology
Pain Management
Palliative Care
Pathology
Other

Specialties — Other (please list)*

Services

Check all that apply.

Molecular Testing — Company Name (if testing is sent out)

If run in-house, leave blank.

Services — Other (please list)*

Common RCC Types

Clear Cell RCC
Chromophobe RCC
Papillary RCC
Other Expertise

Other Expertise — Please list*

Rare / Aggressive RCC Subtypes

Collecting Duct RCC
FH-deficient RCC
Renal Medullary Carcinoma
Sarcomatoid
Translocation RCC
Tuberous Sclerosis-associated RCC
Unclassified RCC
VHL-associated RCC
Other

Rare/Aggressive RCC Subtypes — Other (please list)*

Other Kidney Tumors

Renal Sarcoma
Rhabdoid Tumor
Wilms Tumor
Other

Other Kidney Tumors — Other (please list)*

Special Situations

Special Situations — Other (please list)*

Select the appropriate range for each metric based on calendar year 2024.

Kidney Cancer Surgery Volume (2024)

Clear Cell Kidney Cancer Diagnosis Volume (2024)

Radiation & Ablation Procedure Volume (2024)

Non–Clear Cell Kidney Cancer Diagnosis Volume (2024)

Clinical Trial Participation Volume (2024)

Special Programs & Recognition (Check all that apply)

NCI Designated Cancer Center
Government-Funded Research
Consortium Member (please specify)
American College of Surgeons Accredited Cancer Program
Other

Consortium Member — Please specify*

Special Programs & Recognition — Other (please list)*

Types of Research Conducted

Research Lab
Clinical
Translational
Population-Based
Multi-Institutional Collaboration
Other

Multi-Institutional Collaboration — List institutions with active collaborations

Types of Research — Other (please list)*

On-site Patient Resources & Support Services

Other Notable Services — Please list*

Please list the primary insurance carriers your institution accepts (include Medicaid plans and specify the states covered):

Enter one carrier per line. Apostrophes and hyphens are allowed.

Please list any major insurance carriers your institution does not accept:

Trial Name / Description / NCT

Trial Name	Trial Description	NCT

Add each open trial as a new row.

Website link to full trial list

Would you like to receive printed patient education materials?

Yes
No

Are there physicians at your institution interested in:

Speaking at KCA events/webinars
Contributing to educational resources
Participating in research collaborations or advisory panels
Other

Physician Interests — Other (please list)*

Program Engagement Opportunities

Women in RCC (WiRCC)
Young Investigator Opportunities
Patient Roundtables/Focus Groups
Community Events/Fundraisers
Research Grant Collaborations
Mentorship Opportunities
Policy / Advocacy Engagement
Provider Education Initiatives
Other

Program Engagement Opportunities — Other (please list)*

Department/Role

Title/Position

First Name

Credentials (MD, PhD, etc.)

Confirmation*

I confirm that all information in this form is filled in and complete.

Submitted By*