Colorectal & Breast And Cervical Screening Programs Enrollment Form - Wyoming Department Of Health Page 3
ADVERTISEMENT
1
2
3
4Office use only
Copy to:
Colorectal & Breast and Cervical Screening Programs Enrollment Form
I am enrolling in:
Check box
WBCC
And/Or
WCCSP
Breast & Cervical
Colorectal
First Name
Initial
Last Name
Maiden Name
(if applicable)
Mailing Address
City
State
Zip
Birth Date
Age
/
/
______
How did you hear about the program?
Home Phone
Work Phone
Cell Phone
Doctor
Friends
Breast & Cervical Program
Radio
Alternate Contact:
Family
Poster
Contact person: ___________________________________________
Community Event
Television
Relationship:________________ Phone: (___)___________________
Mailing/Flyer
Free Clinic/CHC
IHS
Health Fair
What race/ethnicity are you? (check all that apply)
Other healthcare provider
Website
Male
American Indian
Black/African American
Public Health Nurse
White
Asian
Pacific Islander/Hawaiian
Wyoming Cancer Resource Services (WCRS)
Female
Newspaper/Magazine
Hispanic/Latino
Unknown
Other__________________________
Other_______________________________
What is your primary language?
Name of Health Care Provider (
applicable)
If
Name---------------------------------------------
English
Spanish
Other
Phone : (
) ----------------
______________________________________________________________
Name of clinic:--------------------------------------------
Social Security Number: (Optional) ___ __ ____
City: ------------------------------
Insurance Information
(
The WCCSP serves Wyoming residents that are uninsured and underinsured. Please notify your healthcare provider of any
private insurance, they must bill your insurance before they bill the
WCCSP.)(The WBCC serves only uninsured residents)
Do you currently have private insurance?
Yes
No
Don’t Know
Does it cover the cost of a colonoscopy?
Yes
No
Do you have Medicare?
No
Yes
Part A only?
or
Part A& B
Do you have Medicaid? □ No
□ Yes
Current Income ( list gross before taxes)
Your current monthly household income:----------------
How many people live on this income? ------------------
Office use only:
Patient: Sign name -----------------------------------------
Approved---------------------
Denied------------------------
Print Name : -------------------------------------------------
Date: -------------------------
Staff Notes: -----------------------------------
Today’s Date : ----- /-----/----- (mm/dd/yyyy)
--------------------------------------------------
How many family members (parents, brothers, sisters, and children)
--------------------------------------------------
have been told they
cancer
ha
StateID# ---------------------------------
Consent, Release & Confidentially Statement
The information I have provided is accurate to the best of my knowledge. I understand that if I am accepted into this program, and I have
knowingly provided false information, I may be required to repay any benefits I have received. I understand that I could be prosecuted for
fraud if: (a) I have provided false information and/or (b) any changes to my income and/ or insurance status are not reported after I am
enrolled. By agreeing to take part in this program, I give my permission to healthcare providers, billing agencies, Wyoming Department
of Health, Wyoming Breast and Cervical Cancer Early Detection Program, the Colorectal Screening Program the Centers for Disease
Control and Prevention, and others involved in my care to share medical information obtained for the purpose of screening, diagnosis,
treatment, and program evaluation.
I understand that information received by the Wyoming Breast and Cervical Cancer Early Detection Program or the Colorectal Screening
Program will be treated as confidential and that any uses and disclosures will be in accordance with Wyoming Department of Health
(WDH) policies. For additional information regarding WDH uses and disclosures of protected health information, visit the Department’s
HIPAA website.
Revised 11-2016
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Ph 3151 - Wic (women, Infants And Children) Program Referral Form - Tennessee Department Of Health
Legal
Form Nih 2762-3 - Undergraduate Scholarship Program (ugsp) - Academic Enrollment Certification And Service Obligation Deferment Request - U.s. Department Of Health And Human Services
Legal
Form Wic-48 - Louisiana Women, Infant And Children (wic) Special Supplemental Nutrition Program Form - Louisiana Department Of Health And Hospitals
Legal
Wyoming Sales/use Internet Filing Service Electronic Agreement Form - Wyoming Department Of Revenue (2006)
Financial
Related Categories
Parent category: Legal