WISEWOMAN Enrollment & Consent Form

  • WISEWOMAN Enrollment Form

  • Eligibility Enrollment Information

  • Date of Birth*
     - -
  • Do you have health insurance?*
  • Format: (000) 000-0000.
  • Is it okay for the WISEWOMAN program to leave a detailed voicemail on this phone?*
  • I am also enrolled in the Montana Cancer Screening Program, which is a program that helps eligible women pay for breast and cervical cancer screenings.*
  • I am interested in receiving more information about the Montana Cancer Screening Program.

  • Demographic Information

  • Are you of Hispanic or Latino origin?*
  • What race do you primarily identify as?*
  • If you are multi-racial, what is the secondary race you identify as?

  • Social Determinants of Health Screening

  • Do you own any of the following: desktop computer, laptop computer, smartphone, tablet, or portable computer?
  • Do you or any member of this household have access to internet?
  • During the last 12 months, was there a time when you were worried you would run out of food because of a lack of money or other resources?
  • Have you ever missed a doctor's appointment because of transportation problems?
  • If you are currently using childcare services, please identify the type of services you use. If not, select 'Not Applicable'
  • Have you had any of these childcare related problems during the past year? (Select all that apply)
  • What is your housing situation today?
  • The following will ask about how safe you feel. How often does your partner physically hurt you, insult you, or talk down to you?
  • If you are not currently taking medication for a chronic health condition, please skip this question. Do you ever forget to take your prescribed medication, are careless at times about taking your medication, stop taking your medication when you feel better, or stop taking your medication if it makes you feel worse?

  • Informed Consent

  • WISEWOMAN Information

    The Montana Cardiovascular Health Program has a grant from the Centers for Disease Control and Prevention (CDC) for WISEWOMAN heart disease services. The program helps with heart disease screenings for low-income women, ages 35-64, who don’t have health insurance, are not on Medicaid, or who are under-insured. To be a part of WISEWOMAN, the woman must be eligible for breast and cervical cancer services offered by the Montana Cancer Control Programs.

    The heart disease screenings will be done three times:

    1) First screening
    2) Follow-up screening (you will schedule this with your WISEWOMAN doctor)
    3) Third screening (12-18 months after first screening)
     

    The screenings with your WISEWOMAN doctor will include:

    Birthday, race, ethnicity, county and zip code where you live, main language you speak, etc.
    Measuring your blood pressure, cholesterol, blood sugar, height, weight, and waist
    Talking about any heart disease risks you have, your usual eating habits, how active you are, and if you smoke
    Talking about medicines you take to lower blood pressure, cholesterol, or blood sugar
    Talking about any issues you might have with housing, transportation, or access to food
    Learning about how to lower your heart disease risk
    Referring you, if needed, to lifestyle management programs or services to help manage heart disease risk or your social needs
    NOTE: During your screening, if your blood pressure top number is more than 180 OR the bottom number is more than 120, your WISEWOMAN doctor will recheck your blood pressure within seven days.

    Insurance Information

    I understand that I may be billed for services not covered by my insurance or WISEWOMAN.

    Confidentiality

    Any information that I (the WISEWOMAN patient) share will be confidential. The information will be available only to me, my WISEWOMAN doctor, and WISEWOMAN staff.  WISEWOMAN staff includes employees at the county health department, clinic, and state health department who work on the WISEWOMAN grant. Program reports will include information on groups of patients and will not identify anyone by name.

    Consent to Share Health Care Information

    I consent to and authorize sharing my records (screenings and referrals) with the WISEWOMAN staff for up to six months past the time when the third screening is done.

    Commitment to Participate

    I understand that I am agreeing to three clinic visits and participation in at least one lifestyle management program if recommended by my doctor. I agree to answer phone calls, text messages, or other ways of communicating.  I understand that my participation is voluntary and that I may drop out of the WISEWOMAN program at any time. If I would like to leave the program, I will contact the program lead.

  • I have read the information above, talked about WISEWOMAN services, and agree to be part of the WISEWOMAN program.  If I had any ask questions about WISEWOMAN, they were answered. All information I gave to WISEWOMAN staff (including whether I have health insurance) is, to the best of my knowledge, true. I give permission for Logan Health and Flathead City-County Health Department to share my patient information for the purpose of WISEWOMAN.*
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