• Breast and Cervical Cancer Screening Eligibility Form

    Lewis and Clark Public Health
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Messages regarding eligibility/appointments ok at these numbers?

  • Ethnic Background

  • Are you Hispanic (Spanish/Hispanic/Latino)?*
  • Race: Check all races that apply*

  • 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?
  • Referral Date:
     - -

  • Medical Background

  • Are you having breast problems?
  • Date of last mammogram:
     - -
  • Do you have implants?
  • Do you have a history of breast cancer?
  • Date of last Pap test?
     - -
  • Have you had a hysterectomy?
  • If yes, due to cervical cancer?
  • If yes, do you still have a cervix?

  • Tobacco Use Cessation   MT QUIT LINE: 1-800-QUIT-NOW

  • Do you use tobacco?
  • How did you hear about the program?

  • How can we help?

    Our mission is to improve and protect the health of Montanans by creating conditions for healthy living.

    What health areas would you like assistance with?

  • Patient Navigation Services

    The Montana Cancer Control Program provides free of charge, patient navigation services to women who do not meet the eligibility requirements to receive free breast and cervical cancer screening services. 

    If you do not meet the eligibility requirements and choose to enroll for our free patient navigation services, you will be provided with assistance to overcome barriers and to facilitate timely access to quality breast and cervical cancer screening and diagnostic services.

  • U.S. Military Veterans

  • Are you a veteran of the U.S. Military?
  • If yes, can we share your contact information with a representative with the U.S. Department of Veteran Affairs?

  • Are there any circumstances that might prevent you from receiving your cancer screening services?

  • Please describe those circumstances below. If none, check None
  • Do you need assistance with any of the following to access medical services? Check all that apply
  • What resources are you or your family interested in learning more about from the following topics? Check all that apply

  • PLEASE READ AND SIGN

    Informed Consent and Authorization to Disclose Health Care Information

    The Montana Cancer Control Program (MCCP) receives funds from the Center for Disease Control and Prevention (CDC) to provide breast and cervical cancer screening services for age and income eligible women.  Each time a woman is screened for breast cancer, she may receive a clinical breast exam and breast X-ray called a mammogram. For cervical cancer, she may receive a pelvic examination and a Pap test. If any of the initial tests for breast and cervical cancer are abnormal, further diagnostic testing may be required, which may include a diagnostic mammogram, ultrasounds and/or biopsy of the breast or cervical tissue. MCCP will provide patient navigation services that will help you complete all the diagnostic tests and find resources that may help for treatment (if necessary). By enrolling in the MCCP you are accepting responsibility for keeping appointments and completing all screening and diagnostic tests that are recommended by your medical provider.

    Services Not Covered

    The MCCP only provides services for breast and cervical cancer screening and limited diagnostic tests. The program does not cover services for other health conditions, some diagnostic services, or cancer treatment. If I need services that are not covered, the MCCP staff will refer me to agencies that may help provide treatment. I understand that I may be billed for services not covered by the MCCP.

    Patient Navigation Services

    I understand if I do not meet the eligibility requirements for MCCP and have chosen to enroll for patient navigation services only, MCCP is not financially responsible for any medical expenses incurred by me while enrolled for patient navigation services only.

    Insurance Information

    I understand if I do not meet the eligibility requirements for the MCCP and have insurance coverage, excluding Medicare Part B and Medicaid, I still may be eligible to participate. However, my insurance will be billed first for cancer screening services. If the services are not fully reimbursed up to the maximum allowable Medicare reimbursement rate by my insurance, the MCCP will pay the unpaid balance up to the maximum allowable Medicare reimbursement rate.

    Confidentiality

    Any information provided by me will remain confidential, which means that the information will be available only to me, my health care provider, and to the MCCP staff. The MCCP staff means those personnel and the Montana Department of Public Health and Human Services, administrative site and the tribal organizations and Indian Health Service Units who are specifically designated to work in the MCCP. Program reports will include information on groups of clients and will not identify any client by name or tribal affiliation.

    Authorization to Disclose Health Care Information

    I consent to and authorize the mutual exchange of screening and diagnostic records among the MCCP staff, my health care provider(s). and/or Pap smear and the radiology facility where my mammogram is performed with respect to MCCP related services received by me up to six months after the date indicated below. This authorization expires thirty months after the date I signed below.

    I have read the information provided herein, discussed this and other information about the MCCP staff and agree to participate in the program. I have had an opportunity to ask questions about the MCCP and have received answers to any questions I had. All information, including financial insurance benefits, I have provided to the MCCP is, to the best of my knowledge, true. I understand that my participation is voluntary and that I may drop out of the MCCP at any time.

  • Date:
     - -
  • Should be Empty: