Cancer Screening Voucher
Application Form
Section 1 - Applicant Information (Head of Household if minor)
Name
*
First Name
Last Name
Middle Name (If applicable)
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing address if different from above
Back
Next
Language Preference
English
Spanish
Please attach proof of residency - one of the following (Lease/Rent Receipt/Utility Bill/Mortgage Statement/Colorado Driver's License/Letter from Local Agency)
*
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of
Section 2 - Insurance Information
Do you have active health insurance coverage?
*
Yes
No
If Yes, Insurance Provider
Policy #
Deductible
If Yes, Please include a copy of your insurance card
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of
Please explain if your insurance will not cover the screening
Section 3 - Voucher Type Information
Screening Required for
Please Select
Breast Mammogram
Colon (FIT) Test
Lung (LDCT)
Prostrate (PSA Blood Test)
Physician Referral
*
Yes
No
Physician Name
*
If you don't have one please type None
Current provider if different from above
*
If you don't have one please type None
Have you had a screening before?
*
Yes
No
If Yes, when and what was the result?
Are you currently showing symptoms?
*
Yes
No
If Yes, please explain
Do you have a history of cancer in your family?
Yes
No
If Yes, please explain
Please tell us where you saw the application or received it from
Section 4 - Authorization and Signature
By signing, I certify that all information provided is true and complete to the best of my knowledge. I understand that submission of this application does not guarantee assistance, and that vouchers are distributedbased on available funding and need.
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
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