Free Mammogram Sign Up Form

Free Mammogram Sign Ups
Liability Waiver and Release
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Cell Phone Number
Please enter a valid phone number. This number may be called to set up the mammogram screening appointment.Format: (000) 000-0000.
Please give a second number where you can be reached
This number will be called if we are unable to reach you at the first number.
Zipcode

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have medical insurance?
What type of medical insurance do you have? (Note: You may be referred to a mammogram screening site if you have insurance.)
Are you 40 years of age or older? Note: If you experiencing breast related issues, after completing this form, immediately call the Illinois Department of Public Health Women's Health-Line and request an appointment at 1-888-522-1282, or you may contact another medical clinic for help. For all life-threatening emergencies call 911.
If you are under 40 do you have a family history of breast cancer, or are your experiencing issues with your breast? Note: If you experiencing breast related issues, after completing this form, immediately call the Illinois Department of Public Health Women's Health-Line and request an appointment at 1-888-522-1282, or you may contact another medical clinic for help. For all life-threatening emergencies call 911.
By completing this form you agree to be contacted about breast health or other health related programs by Healthy Washington Heights, Beyond A Mammogram, Health Research and Awareness NFP, Illinois Breast & Cervical Cancer Program, and other collaborating organizations.
Will you share this form with someone else that may need a free mammogram? To do this you can share the URL by text, social media and email. Here is the URL: https://bit.ly/FREE_MAMMOGRAMS. Or, copy the QR code below and forward to uninsured women that need a mammogram. Send out the URL or QR code AFTER you have completely submitted this form.
Which organization referred you?
If you selected "other" for the organization that referred you, type the name of who told you about this program in the space provided below. This can be the name of an organization or an individual.
HRANFP-Confirm the type of insurance that the person has (talk with the IBCCP to confirm).
HRANFP-If the person that signed up has insurance why did they sign up? Do they have a high insurance deductible? Do they have a regular primary care physician that helps to direct them to screens on a normal frequency? Is there another reason? Find out from talking with the person that signed up?
HRANFP-Date of 1st Follow Up Call to person, if needed (record reason for call in the field provided).

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
HRANFP-Was a mammogram screen provided.
HRANFP-Date of the 1st SCHEDULED mammogram screen (if known).

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
HRANFP-Date of 2nd Follow Up Call to person, if needed (record reason for call in the field provided).

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
HRANFP-Date of 3rd Follow Up Call to person, if needed (record reason for call in the field provided).

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
HRANFP-Date of mammogram screen

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
HRANFP-Is a diagnostic mammogram needed?
HRANFP-Date of diagnostic mammogram

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
HRANFP-Is a biopsy needed?
HRANFP-Is treatment needed?
HRANFP-Enter update information here (like details from the follow up call, information on why a person with insurance signed up for a free mammogram, etc.).
HIPAA Release
Sign below to agree to the HIPAA Release. Please read it before signing.
If you are uninsured, under-insured, or have Medicaid and would like to get a free mammogram complete the fields below.

By signing up you agree and acknowledge that you are voluntarily using this form, are solely responsible for your health, and will not hold Health Research and Awareness NFP, Beyond A Mammogram, Healthy Washington Heights, partners, affiliates or other community based organization associated with this initiative to connect you with a mammogram screen. Note: Mammograms and follow up care/treatment may be provided for free or no charge by the state of Illinois to women that do not have insurance through the IBCCP program. The determination of who does not have insurance is made by the IBCCP clinics or state of Illinois. For problems with completing this form contact Health Research and Awareness NFP at 773-688-9186.
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Free Mammogram Sign Ups

If you are uninsured, under-insured, or have Medicaid and would like to get a free mammogram complete the fields below.