Women’s Health Check Enrollment

Women’s Health Check Enrollment
Eligibility-Enrollment Information
Today’s date

MonthDayYear
Date
Last Name
Middle Initial
First Name

First NameFormer Last name
Date of Birth

MonthDayYear
Date
Social Security Number
Address

Mailing Address

Street Address Line 2

CityState

Zip
County
County
YesNo
Home phone number
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell phone number
Format: (000) 000-0000.
E-Mail Address
example@example.com
WhiteAmerican Indian or Alaska NativeBlack or AfricanAsianNaïve Hawaiian or Other Pacifica IslanderOther/Unknown
YesNoUnknown
EnglishSpanishOther
YesNo
YesNo
Place of Birth (State or Country)
yesNo
Alien ID#
Date Legal Resident Status

MonthDayYear
Date
YesNo
Date of last mammogram

MonthDayYear
Date
Location of last mammogram
YesNo
YesNoUnknown
If yes, who?
YesNo
YesNo
YesNo
Date of your last pap

MonthDayYear
Date
Location of your last pap
YesNo
YesNoUnknown
YesNo
If yes, name of Insurance Company
YesNo
YesNo
      If WHC staff cannot reach you by mail or phone, WHC staff may contact the following person for the purpose of obtaining your current address or phone number. Please provide the names and telephone numbers of one or two people who can always reach you.
Name: Name:
Relationship: Relationship:
Phone number:    Phone Number:
Re-screen/Previously EnrolledFree ClinicWHC Reminder post cardSocial Media Facebook, Instagram, etcFlyer/Poster/BrochureNewspapers/TV/RadioInternetMedical Provider (Name of Provider listed below)Other
Family/Friend/Word of MouthEvent (Name of Event)Other organization Komen, community agency, etc
Medical Provider (Name of Provider)
Event (Name of Event)
Difficulty with hearingDifficulty concentrating, remembering or making decisionsDifficulty with visionDifficulty with mobility, such as walking or climbing stairsNoneOther
Tobacco Use Cessation ID Quit Line: 1-800-QUIT-NOW
YesNo
CigarettesElectronic Devices (vapes, e-cigs)Chewing Tobacco
I am planning to quit. I agree to have the QuitLine call me. I understand that my participation is voluntary, and that the Idaho Tobacco QuitLine is a free service.I am planning to quit, but I do not want a quit line coach to call me. I would like to learn more about other resources.
Self-Attestation of Income
Household Size– To determine your household size, include yourself (and if married, your spouse); and, dependent children 18 . years or younger.
Number in home
Total Family Income
MonthlyYearly

Gross Income

Rows	Name of Person Receiving Income	Employer or Source of Income	Annual Gross Income (before taxes)	Monthly Gross Income
Person 1
Person 2
Person 3

Income - Income includes salary and wages, tips, alimony, public assistance, disability, unemployment, Social Security, interest, retirement and pension. Include only income for adults in household.
Received How
If you report $0 income, please provide a brief explanation of how you are surviving financially
Women’s Health Check involves a cooperative effort between clinics, doctors, program evaluators, mammography facilities, laboratories, the Idaho Department of Health & Welfare, and the Centers for Disease Control and Prevention CDC The purpose of this program is to encourage screening for breast and cervical cancer for women who are low-income U.S. citizens or eligible non-citizens who have no other way to pay for screening tests no private insurance, Medicare or Medicaid coverage to pay for these tests. The purpose of the screening is to prevent cancer or detect cancer at its earliest state so that it can be successfully treated. Screening for cervical cancer involves a pelvic examination and a Pap test. Screening for breast cancer involves a mammogram. If needed, certain approved diagnostic tests may be available at no cost to you. Should you need treatment for cancer, you may qualify for treatment through the Breast and Cervical Cancer Medicaid Program.
1. My signature certifies that the information on this application is true and correct; and I have read and understand the program description (above) of the Idaho Women’s Health Check Program (WHC), understand that I am eligible for the program, and hereby consent to receive the health services as indicated above. 2. I understand that my participation in this Program is voluntary, and that I can drop out of the Program at any time. 3. By signing this form, I am stating that I understand that if I do not complete a full screening as indicated, I may be responsible for some or all the costs. 4. A healthcare provider may ask for diagnostic tests that are not covered by Women’s Health Check. If additional tests are ordered, I understand that I will make arrangements for payment with the healthcare provider for the tests or services not covered by Women’s Health Check. 5. By agreeing to take part in this program, I give permission to all of my doctors, clinics, mammography facilities, and/or hospitals to provide all information concerning my PAP tests, breast exams, mammograms and any related diagnostic and treatment procedures to the WHC program. Case managers employed by the program may contact me for purpose of gathering information to help me access important tests and exams for adequate follow-up of abnormal test results Public Health District Tobacco Coordinators may contact me should I elect to participate or receive tobacco cessation services and/or resources. 6. Any information I give to WHC and participating providers is confidential. This means that WHC will not disclose or share my information, except for the minimum necessary to administer the Program described above. Reports, which result from this Program, will not use my name or any other identifying information. 7. If I should be diagnosed with cancer or pre-cancerous conditions, I may qualify for treatment through the BCC Medicaid program and agree to release my information to Medicaid to determine if I am eligible for treatment. 8. Women’s Health Check routinely follows up with participants to learn about their experiences with the program. By signing this form, I am stating that I give my permission to be contacted by a program evaluator for the opportunity to participate in a follow-up survey. 9. I have been offered the opportunity to read the Idaho Department of Health and Welfare’s Notice of Privacy Practices (also available at www.healthandwelfare.idaho.gov).
YesNo
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Women’s Health Check Enrollment

Eligibility-Enrollment Information

Tobacco Use Cessation ID Quit Line: 1-800-QUIT-NOW

Self-Attestation of Income

Received How