Breast And Cervical Eligibility Form - The Montana Cancer Control Programs Page 2
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Social Security Number:
Client Name:
Informed Consent and Authorization to Disclose Health Care Information
The Montana Cancer Control Programs (MCCP) receives funds from the Center for Disease Control and Prevention (CDC) to provide
cancer screening for age and income eligible Montana residents. Montana women can be screened through this program for breast
and cervical cancers. Each time a client is screened for breast cancer, they may receive a clinical breast exam and breast X-ray called
a mammogram. For cervical cancer, a client may receive a pelvic examination and a Pap test. If any of the initial tests for breast and
cervical cancer are abnormal, further diagnostic testing may be required, which may include a diagnostic mammogram, ultrasound,
and/or biopsy of the breast or cervical tissue. MCCP will provide patient navigation services that will help you complete all the
diagnostic tests and find resources that may help for treatment (if necessary). By enrolling in the MCCP you are accepting
responsibility for keeping appointments and completing all the screening and diagnostic tests that are recommended by your
medical provider.
Services Not Covered
The MCCP only provides services for breast and cervical cancer screening and limited diagnostic tests. The program
does not cover services for other health conditions, some diagnostic services, or cancer treatment. If I need services that are not
covered, the MCCP staff will refer me to agencies that may help provide treatment. I understand that I may be billed for services
not covered by the MCCP.
Insurance Information
I understand I have met the eligibility guidelines for the MCCP. I may have insurance coverage and still be eligible to participate.
However, my insurance will be billed first for cancer screening services. If the services are not fully reimbursed by my insurance,
the MCCP will pay the unpaid balance up to the maximum allowable Medicare reimbursement rate.
Confidentiality
Any information provided by me will remain confidential, which means that the information will be available only to me, my
health care provider, and to the MCCP staff. The MCCP staff means those personnel and the Montana Department of Public Health
and Human Services, administrative site and the tribal organizations and Indian Health Service Units who are specifically
designated to work in the MCCP. Program reports will include information on groups of clients and will not identify any client
by name or tribal affiliation.
Authorization to Disclose Health Care Information
I consent to and authorize the mutual exchange of screening and diagnostic records among the MCCP staff, my health care
provider(s), the laboratory reading my Pap smear, and the radiology facility where my mammogram is performed with
respect to MCCP related services received by me up to six months after the date indicated below. This authorization expires thirty
months after the date I signed below.
I have read the information provided herein, discussed this and other information about the MCCP and agree to participate in the
program. I have had an opportunity to ask questions about the MCCP and have received answers to any questions I had. All
information, including financial and insurance benefits, I have provided to the MCCP is, to the best of my knowledge, true. I
understand that my participation is voluntary and that I may drop out the MCCP at any time.
Would you like to subscribe to a monthly newsletter?
Yes
No
Client Signature: _____________________________________
Date:
MM / DD / YYYY
Print Full Name: ______________________________________
Submit
Data Collection Forms Version: .docx July 2015
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