• Breast and Cervical Cancer Screening Eligibility Form

  • Eligibility-Enrollment Information

  • Birtdate*
     - -
  • Format: (000) 000-0000.
  • Is it ok to leave messages regarding eligibility/appointments on these phones?*

  • Ethnic Background

  • Race

  • Which race(s) best describe(s) you?*

  • HealthCare Coverage

  • Do you have Medicare Part B?*
  • Do you have Medicaid?*
  • Do you have health insurance*
  • Have you been referred to the Marketplace for health insurance or Expanded Medicaid Plans?
  • Date referred
     - -

  • Medical Background

  • Are you having any breast problems?
  • Have you ever had a mammogram
  • Date of last mammogram
     - -
  • Do you have breast implants?
  • Do you have a personal or family history of breast cancer?
  • Have you ever had a Pap test?
  • Date of last Pap test
     - -
  • Have you had a hysterectomy?
  • If yes, was it due to cervical cancer?
  • If yes, do you still have a cervix?
  • Are you up-to-date on your HPV vaccinations?
  • Are there any circumstances that might prevent you from receiving your cancer screening services?
  • Do you use tobacco?
  • How did you hear about the program? (Check all that apply)

  • Informed Consent and Authorization to Disclose Health care Information

  • Purpose: I understand that the purpose of this authorization is to allow my healthcare provider to disclose my health information to appropriate agencies or organizations involved in breast and cervical cancer screening programs.
    Information Disclosure: I authorize my healthcare provider to disclose relevant health information, including but not limited to medical history, laboratory test results, imaging studies, and treatment records, to authorized personnel involved in the screening program.
    Confidentiality: I understand that my health information will be treated confidentially and will only be disclosed to authorized individuals or entities involved in the breast and cervical cancer screening program. I acknowledge that appropriate safeguards will be in place to protect the privacy and security of my health information.
    Purpose Limitation: I understand that my health information will only be used for the purpose of determining my eligibility for breast and cervical cancer screening and will not be disclosed for any other purpose without my further authorization, except as required by law.
    Right to Revoke: I understand that I have the right to revoke this authorization at any time by providing written notice to my healthcare provider. However, I acknowledge that revoking this authorization may affect my eligibility for breast and cervical cancer screening services.
    Signature: By signing below, I acknowledge that I have read and understood the terms of this informed consent and authorization to disclose health care information. I voluntarily consent to the disclosure of my health information for the purpose described above.

  • Date*
     - -
  • Clear
  • Should be Empty:
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