Mammogram Application

Mammogram Application - English

Apply for a mammogram screening and assistance program. Please complete all required sections.
Eligibility Information
To qualify for this program, you must:
- Be a woman aged 40 or older (or younger with a doctor’s order)
- Have no insurance or insurance that does not cover mammograms
- Live in the service area
- Not have had a mammogram in the past 12 months
- Not be experiencing breast symptoms (such as a lump, pain, or discharge)
- If you are, please consult your doctor immediately
Applicant Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
PhoneEmail
YesNo
If yes, please provide your insurance provider name:
Medical History
YesNo
If yes, when was your last mammogram?

MonthDayYear
Date
YesNo
YesNo
If yes, please describe your symptoms:
YesNoNot Sure
Consent and Authorization
By signing below, I certify that the information provided is true and complete. I understand that this application does not guarantee eligibility or approval for a mammogram. I authorize the program to contact me regarding my application and to share my information with healthcare providers as needed for scheduling and follow-up.
Applicant Signature*
Date Signed*

MonthDayYear
Date
Should be Empty:

Mammogram Application - English