Colorectal & Breast And Cervical Screening Programs Enrollment Form - Wyoming Department Of Health

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Enrollment Application
Checklist
Check box or boxes for which program you chose to enroll
Wyoming Breast & Cervical Cancer Program (WBCC)
(free mammogram & Pap test)
Wyoming Colorectal Screening Program (WCCSP)
(free colonoscopy)
Read, complete and sign the following documents:
Enrollment Application
 Answer all questions for the procedure(s) you are applying for
 Please print clearly in blue or black ink
Please submit the application by mail or fax:
Mailing Address:
Wyoming Integrated Cancer Services
6101 Yellowstone Road, Suite 510
Cheyenne, WY 82002
Fax:
(307) 777-3765
Phone:
(307) 777-3699 or 1-800-264-1296
Website:
2016 Federal Poverty Guidelines
Income guidelines used to determine eligibility if you qualify for a free colonoscopy or Pap test and
Mammogram
:
(Based on gross income before taxes are removed)
Number of Persons
250%
in Family Unit
Poverty Guidelines
Monthly
Hourly
1
$29,700
$2,475
$14.29
2
$40,050
$3,338
$19.27
3
$50,400
$4,200
$24.25
4
$60,750
$5,063
$29.23
5
$71,100
$5,925
$34.21
6
$81,450
$6,78
$39.19
7
$91,825
$7,652
$44.18
8
$102,225
$8,519
$49.18
Each additional
$10,400
$867
$5.00
person, add
The Wyoming Colorectal Cancer Screening Program & the Breast and Cervical Cancer Early Detection Program use 250% poverty
guidelines to determine eligibility. Poverty guidelines are updated annually by the federal government. You can find the current
poverty guidelines at https://aspe.hhs.gov/poverty-guidelines

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