Breast And Cervical Eligibility Form - The Montana Cancer Control Programs
Download a blank fillable Breast And Cervical Eligibility Form - The Montana Cancer Control Programs in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Breast And Cervical Eligibility Form - The Montana Cancer Control Programs with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Breast and Cervical Eligibility Form
Eligibility-Enrollment Information
What is your age?
Family’s yearly income before taxes?
Number of people in household?
Last Name
First Name
Middle Initial
Other Last Names Used
Birth Date
Social Security Number
State
County
Mailing
Street
City
Address
Address
Zip
Email
Home/Cell Phone
Insurance Information
Yes
No Referred to Marketplace for eligibility assessment for subsidized health insurance or Expanded Medicaid plans?
Date Referred
MM / DD / YYYY
Yes
No Do you have health insurance?
Insurance Company
What is the co-insurance amount?
Yes
No Do you have Medicaid?
What is the deductible amount?
Yes
No Do you have Medicare Part B?
Ethnic Background
Medical Background
Are you Hispanic? (Spanish/Hispanic/Latino)
Are you having any breast problems?
Yes
No
Yes
No
Unknown
Do you have breast implants?
Yes
No
Race Which race(s) best describe(s) you?
Have you ever had a mammogram?
Yes
No
White
Date of last mammogram
MM / DD / YYYY
American Indian or Alaska Native
Have you ever had a Pap test ?
Yes
No
Black or African American
Date of last Pap test
Asian
MM / DD / YYYY
Native Hawaiian or Other Pacific Islander
Ha ve you ever had a hysterectomy?
Yes
No
Due to cervical cancer?
Unknown
Yes
Do you still have a cervix?
No
Yes
No
Disability questions in cooperation with the Montana Disability and Health Program
Yes
No Do you have serious difficulty walking or climbing stairs?
Yes
No Are you deaf; Do you have difficulty hearing?
Yes
No Because of a physical, mental, or emotional condition do you
Yes
No Do you have difficulty dressing or bathing?
have difficulty doing errands alone such as visiting a doctor’s
Yes
No Because of a physical, mental, or emotional
office or shopping?
condition, do you have serious difficulty
Yes
No Are you blind; Do you have serious difficulty seeing even when
concentrating, remembering, or making
wearing glasses?
decisions?
Yes Do you decline to answer the disability questions?
Do you use tobacco?
Yes
No If Yes, refer the client to the Montana Quit Line. 1(800) QUIT-NOW
How did you hear about the program? (Check all that apply)
HCC Bus
Internet
Pink/Purple Card (Pamphlets)
Re-screen/Previously Enrolled
Family/Friend/Word of Mouth
Presentation
MAIWHC
Fair-Job/Health or Pow Wow
Special Promotion/ Promotional Ad
Newspaper/Newsletter
Medical Provider Name (if applicable):
Government Office
Radio
TV
Please READ and SIGN the Informed Consent and Authorization to Disclose Health Care Information
Office Use Only
Name of Provider: _________________________ Service:_________________________ Date of service:_________________________
Data Collection Forms Version: .docx July 2015
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal