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 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