NJ Cancer Education & Early Detection (NJCEED) Program Consent Form

The NJCEED Program provides breast, cervical, colorectal, and prostate cancer screenings for eligibleuninsured or underinsured New Jersey residents. I have received information about the benefits andrisks of these screening services. I authorize the following screening(s):
2. I hereby AUTHORIZE the following health screenings.
Date of Last Mammogram and Place of Service:
Date of Last Pap Test and Place of Service:
Do you have Health Insurance Coverage? If yes, write the name of the insurance coverage and policy number below.
Insurance Group/ID Number
I attest that the information stated above is true and accurate to the best of my knowledge. I understand that if the above information is misrepresented, it may be grounds for suspension of program services and that I may be required to pay the total actual cost for the services provided to me under the program.
By my signature, I certify that I have read and fully understand this consent statement, that the explanations are understood by me and this consent is given freely, voluntarily, fully informed and without reservation.
Client
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Witness/ Verbal Consent obtained by
Required Documentation
Please upload your photo ID (driver's license, state ID, or passport) and proof of income.

Privacy Commitment: Your information is encrypted and strictly confidential. We do not share data with immigration authorities, ICE, or any other external law enforcement agencies. Your security and privacy are our priority.

Upload your Driver's License, ID, or Passport

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Upload proof of income, pay stub, bank statement, letter of support, or tax return.

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Upload scripts if available

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