Montana Cancer Screening Program Enrollment

Name*

First NameLast Name

Date of Birth*

Date

Social Security Number*

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Are you Spanish, Hispanic, or Latino/a?*

YesNo

Race (Please check all races that apply)*

Family's Yearly Income Before Taxes*

Number of people in household*

Do you have Medicare?*

YesNo

Do you have Medicaid?*

YesNo

Do you have health insurance?*

YesNo

Name of insurance company

Deductible amount

Are you currently having any breast pain or problems?

YesNo

How did you hear about our program?

Referral from healthcare providerSocial media postReminder text from healthcare organizationWord of mouth (friend, relative, etc.)Letter or postcard from Montana Cancer Screening ProgramOther

I am also enrolled in the WISEWOMAN Cardiovascular Health Program, which is a program that helps with heart disease screenings for low-income women, ages 35-64, who don't have health insurance or who are under-insured.

YesNo

I am interested in receiving more information about the WISEWOMAN Cardiovascular Health Program. *Please note this program is currently offered in Bigfork, Lakeside, and Columbia Falls.

YesNo

Informed Consent and Authorization to Disclose Health Care Information:

The Montana Cancer Control Programs (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, ultrasound, 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 the 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.
Insurance Information
I understand I have met the eligibility guidelines for the MCCP. I may have insurance coverage and still be eligible to participate. However, my insurance will be billed first for cancer screening services. If the services are not fully reimbursed by my insurance, the MCCP will pay the unpaid balance up to the maximum allowable Medicare reimbursement rate.
Patient Navigation Services
I understand if I enrolled for patient navigation services only, MCCP is not financially responsible for any medical expenses incurred by me while
enrolled for patient navigation services only.
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 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
and 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.

I have read and agree to the above statement.*

I have read and agree to the above statement.

I provide authorization to disclose health care information as stated in the section titled "Informed Consent and Authorization to Disclose Health Care Information"*

Today's Date*

Date

Name*

First NameLast Name

I would like to see the following provider for my breast exam and/or pelvic exam. (If you have no preference, a provider will be found for you.)

I would like to have my mammogram done here (please check the preferred provider).

The Imaging Center (Kalispell)Logan Health Whitefish (Formerly North Valley Hospital)Cabinet Peaks Medical Center (Libby)Clark Fork Valley Hospital (Plains)St. Joseph Medical Center (Polson)St. Luke Community Hospital (Ronan)St. Patrick Hospital (Missoula)Winkley Mobile Mammography Coach (Polson, Eureka)Other

The following days of the week and times of day are generally convenient for me. (Please select all that apply):*

Additional Comments:

Montana Cancer Screening Program

Patient Enrollment Form

Appointment Request Form: