LLBCF Mammogram Application 2026

Full Legal Name

First NameMiddle NameLast Name

First Name

Last Name

Date of Birth

Date

Age

Immigration / Residency Status

Marital Status

Ethnicity

Race

If Other, please specify

Sexual Orientation

If Other, please specify

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

County

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Alternate Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Preferred Method of Contact

Preferred Language

If Other, please specify

Do you have access to a computer?

Best days/times to contact you

Have you used Libby’s Legacy services in the past

If yes, what services have you received in the past?

How many adults live in your household

How many children live in your household

Please list the ages of the children in your household

Who lives in your household?

Are you currently employed

If yes, what is your employment status?

If yes, who is your employer?

Any other adults working in the household

If yes, how many?

What is your total monthly household income?

Please select all sources of household income

If Other, please explain

Rent / Mortgage Amount Per Month

Utilities Per Month (Optional but Recommended)

Do you currently receive SNAP / Food Stamps?

Do you currently receive Medicaid?

Are you currently experiencing financial hardship

If yes, please briefly explain

Examples: Loss of income, underemployment, medical debt, housing costs, transportation barriers, uninsured, high deductible, etc.

Have you recently experienced any of the following?

Do you have health insurance

If yes, what type of insurance do you have?

Insurance Company Name

If you have insurance, please explain why you need assistance (Required if insured)

Examples: High deductible, out-of-pocket costs, denied coverage, coinsurance, unable to afford follow-up care, etc.

Are you currently experiencing breast symptoms?

If yes, what symptoms are you experiencing and for how long? (Required if Yes)

Examples: Includes lump, pain, skin changes, nipple discharge, swelling, dimpling, redness, or any breast changes.

Do you have breast implants?

Are you currently pregnant?

Are you currently breastfeeding?

Do you have a prescription or referral from a doctor?

If yes, who is the ordering provider?

When and where was your last mammogram?

Do you have the reports and/or image CD(s)?

Have you ever had an abnormal mammogram before?

Have you ever been diagnosed with breast cancer?

If yes, please explain

Do you have a family history of breast cancer?

If yes, who had it and how old were they when diagnosed?

Use your best guess if you do not know the exact age.

Do you have any other personal or family history of cancer you would like us to know about?

Are you able to travel to an imaging center if approved?

How did you hear about Libby’s Legacy?

If referred by a provider, clinic, or organization, please list the name

If referred by a specific person, please list their name

Consent Statement

Emergency Contact Name

First NameMiddle NameLast Name

Relationship to Contact

Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Patient Statement of Understanding

I certify that the information provided in this application is true and complete to the best of my knowledge.

I understand that Libby’s Legacy Breast Cancer Foundation may request additional information or documentation to determine eligibility for services.

I consent to the exchange of information between Libby’s Legacy Breast Cancer Foundation and other community agencies, healthcare providers, imaging centers, and service partners for the purpose of coordinating care and providing needed services.

If I am approved for services, I understand that any appointment changes, cancellations, or reschedules must be coordinated through Libby’s Legacy Breast Cancer Foundation, or I may be billed directly by the service provider.

Important Note:
If you are between the ages of 50–64, please call the BCCEDP office first to request a free mammogram:

Spanish: 407-665-3185
English: 407-665-3244

If we provide this service to you first, it may disqualify you from their program.

Submission of this application does not guarantee approval of services.

Did you read and understand the statement above

Electronic Signature

Type your full legal name

First NameMiddle NameLast Name

Signature Date

Date

Breast Health Services Application

APPLICANT INFORMATION

HOUSEHOLD INFORMATION

INSURANCE INFORMATION

BREAST HEALTH INFORMATION

REFERRAL INFORMATION

EMERGENCY CONTACT

PATIENT STATEMENT OF UNDERSTANDING

ELECTRONIC SIGNATURE