Montana Cancer Screening Program Enrollment

  • Montana Cancer Screening Program

    Enrollment and Appointment Request Form

  • Patient Enrollment Form

    Please fill out the following form. Once submitted, a staff member of the Montana Cancer Screening Program will follow up with you via phone call.
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Is it okay for the Montana Cancer Screening Program to leave voice messages on this phone regarding eligibility/appointments?*
  • Is it okay for the Montana Cancer Screening Program to leave text messages on this phone regarding eligibility/appointments?*
  • Are you Spanish, Hispanic, or Latino/a?*
  • Race (Please check all races that apply)*
  • Do you have Medicare?*
  • Do you have Medicaid?*
  • Do you have health insurance?*
  • Are you currently having any breast pain or problems?
  • How did you hear about our program?
  • I am also enrolled in the WISEWOMAN Cardiovascular Health Program, which is a program that helps pay for heart disease screenings for low-income women, ages 35-64, who don't have health insurance or who are under-insured. For more information on WISEWOMAN, visit https://flatheadcounty.gov/department-directory/health/population-health/wisewoman
  • I am interested in receiving more information about the WISEWOMAN Cardiovascular Health Program. *Please note this program is currently offered in Kalispell, Bigfork, Lakeside, Columbia Falls, and Polson. For more information on WISEWOMAN, visit https://flatheadcounty.gov/department-directory/health/population-health/wisewoman

  • 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. I understand if I have Medicare Part B or Medicaid, I am not eligible for financial assistance.
    Insurance Information
    I understand if I do not meet the eligibility requirements for the MCCP and have insurance coverage, other than Medicare Part B or 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 healthcare 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 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.

  • Today's Date*
     - -

  • Appointment Request Form:

    Please submit the following information along with your patient enrollment form.
  • Do you already have an appointment scheduled?*
  • I would like to have my mammogram done here (please check the preferred provider).
  • The following days of the week and times of day are generally convenient for me. (Please select all that apply):*
  • Should be Empty: