Clone of Ellis Fischel Cancer Center Mammogram Van July 14, 2025

Ellis Fischel Cancer Center Mammogram Van WEDNESDAY, MARCH 4, 2026

Randolph County Health Department parking lot 1319 East Highway 24, Moberly, MO 65270
Name*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number*
Email Address:
Do you have Breast Implants?*

YesNo
Do you have a Language Barrier?*

YesNo
If Client answered YES to either of the above 2 questions please schedule 30 minute slot instead of 15 minute slot.
What is a mammogram?
A mammogram is an X-ray picture of the breast that can be used to check for breast cancer in women, even if they have no signs or symptoms of the disease. Screening mammograms usually involve two or more X-ray pictures
of each breast. The images often make it possible to detect tumors that cannot be felt. Screening mammograms can also find micro calcifications (tiny deposits of calcium) that sometimes indicate the presence of breast cancer.
What is 3D mammography?
Three-dimensional (3D) mammography, also known as digital breast tomosynthesis, is the latest mammogram technology being used for breast cancer screening.
How does 3D mammography work?
A 3D scan takes a series of X-rays of the breast from different angles, creating a three-dimensional image of the breast. The breast is positioned and compressed in
the same way as a conventional mammogram, but because of the 3D view, tomosynthesis has been shown to decrease the number of women who need additional mammogram views to evaluate a possible abnormality.

PATIENT REQUIREMENTS
• Age 30 and above, female only
• Age 30-39 (must confirm insurance coverage; confirmation of coverage and/or if pre-authorization is needed)
• No current breast problems (breast implants are allowed)
• Must be able to climb stairs
• Must be able to stand for duration of mammogram
• Must be at least one year since last mammogram
Are you over 35 years or older? (To be screened on the Mammogram Van you MUST be 35 years of age or older) If you are 35 to 39 years of age please verify with your insurance that a mammogram will be covered and see if a preauthorization is needed.*

YESNO
Insurance
- Ellis Fischel bills insurances
Cancer Screening Services Fund
Women age 30-39 needing a screening mammogram may qualify for the Cancer Screening Services Fund if they:
• Have no insurance or a deductible too high to pay
• Meet 200 percent of poverty level
• Provide proof of income and a picture ID (preferably driver’s license)

Show Me Healthy Women
Women age 40 and older needing a screening mammogram may qualify for Show Me Healthy Women funding if they:
• Provide proof of income and a picture ID (preferably driver’s license)
• Have had a clinical breast exam within the last year

Randolph County 5K Funds
- Age 30 and above, femaile only
- Have no inurance
- Does not qualify for Cancer Screening Services Fund or Show Me Healthy Women program
- When get bill from Ellis Fischel - bring in to Randolph County Health Department and it will be taken care of.
Insurance *
Member ID #*
Group #*
Primary Insured*

First NameLast Name
Relationship to Primary Insured*
COVID-19 vaccines may cause lymph nodes in the armpit to swell, especially on the side where the shot was administered. The swollen lymph nodes are nothing to worry about, but they may look like a lump in a mammogram image.

For this reason, you may want to wait four to six weeks after vaccination before having a routine screening mammogram.

If you’re having a mammogram because of a new breast symptom or abnormal check, don’t delay. It’s important to have these kinds of mammograms as soon as possible, regardless of vaccine date.
If you have had a COVID vaccine what arm did you have the shot in?
Please make sure that on March 4, 2026 it has been at least 1 year and 1 day since your last mammogram.

Please bring an ID and your insurance card to the appointment.
Appointment*
Physican Name needing results*
Signature*

Clear
SCREENING REQUIREMENTS
• Don’t wear deodorant or powders to visit
• Bring insurance card and photo ID
• Know the location and date of last mammogram
• Arrive on time
We will see you on March 4, 2026 at the appointment time you requested. When you arrive please go directly to the Mammogram Van to check in. Thank you!
Should be Empty:

Ellis Fischel Cancer Center Mammogram Van WEDNESDAY, MARCH 4, 2026