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Mammogram Access Project Application

If you or someone you know need a mammogram, please fill out the online application below:

If you are between the ages of 50-64 You MUST call the BCCEDP first to try to have your screening done through the Breast and Cervical Cancer Early Detection Program in order to be eligible for access to treatment through the Medicaid Treatment Act per the State of Florida Option 1.

LLBCF uses the following information to help determine need for free mammograms. All information is kept confidential, unless otherwise stated

Date*
MM slash DD slash YYYY
Name*
First Last
Date Of Birth*
MM slash DD slash YYYY
Age*
Ethnicity/Race*
- Caucasian
- African American
- Hispanic
- Asian
- Other
How do you identify?*
Address*
Street Address City ZIP Code
Home Phone*
Cell Phone
Work Phone
Can we leave a message concerning your appointment with a family member or on your answering machine?*
Email
Who referred you to us today?
Employment Information
Are you currently employed?*
Do you work
Who is your employer?*
If you are not working, why not? Include the year you last worked.
Health Information
Do you have insurance?*
Who is your provider?*
Group number
Member number
Primary Physician/Clinic

**WE CAN REFER YOU TO A PHYSICIAN IF YOU DON'T HAVE ONE**
Physician/Clinic phone number
Date of last mammogram
MM slash DD slash YYYY
Do you have your films?*
If you do not have your films, please provide the name, address & phone number of the Radiology Center
Are you having symptoms?*
Do you have implants?*
If YES, this mobile screening will not be able to meet your needs, but we can still help!
Do you do monthly breast self-exams?*
Do you know how?*
Family history of breast cancer?*
Who had it?
How old were they at diagnosis?
Personal history of breast cancer?*
What type?
When were you diagnosed?
Household Income:
Self
Income above is
Partner
Income above is
Other
(include job income, unemployment, SSI, child support, alimony, etc.)
Rent/Mortgage paid monthly
Food stamp amount monthly
Number of adults in household*
Number of children in household*
List ages*
Patient’s Statement of Understanding
I have read and understand the above and declare the information furnished by me is true and complete to the best of my knowledge. I consent to the exchange of information between Libby’s Legacy Breast Cancer Foundation and other community agencies to provide needed services.
If you are over our income guidelines, a self-pay discounted rate of $80 will be applied, is this acceptable?*
After submitting this form, please allow 1-2 days for processing
I hereby authorize Libby’s Legacy Breast Cancer Foundation to disclose appropriate medical information regarding my care to my primary care doctor.
Name
This field is for validation purposes and should be left unchanged.

Mammogram Access Project Application

Employment Information

Health Information

Household Income:

Patient’s Statement of Understanding

After submitting this form, please allow 1-2 days for processing

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