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Mammogram Application (English)

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.

Name*
First Last
Social Security Number (Optional)
Date of Birth*
Age
Status*
Ethnicity/Race*
How Do You Identify?*
Address
Street Address Apt/Suite City State ZIP Code
County*

Example: Orange, Seminole, Volusia, Osceola, Polk, etc...
Home/Cell Phone*
Work Phone
Best Phone to Call
- Home/Cell
- Work
Best Time to Call
- Morning
- Afternoon
- Evening
Email
Who referred you to us today?*
Have you used Libby's Legacy services in the past?
Financial Information
Are you currently employed?*
If yes, do you work part-time or full-time?
If yes, who is your employer?
How many adults are in the household? (Include yourself)*
How many children are in the household? (18 years old or younger)*
What is the household income per month?*

Includes social security, unemployment, self-employed, standard employment for all adults in the household.
Do you receive food stamps?
Do you have insurance?*
Insurance includes full-medicaid, share-of-cost medicaid, medicare, employer provided insurance, or marketplace insurance.
Breast Health Information
Are you experiencing symptoms? If yes, what symptoms and for how long?*
Includes lump, pain, skin changes, discharge.
Do you have breast implants?*
Do you have a prescription or referral from a doctor?*
When was your last mammogram?*

Use your best guess if you do not remember exact date. If you have never had mammogram, write none or N/A.
If you had a prior mammogram or other diagnostic breast testing, do you have the reports and image CD(s)?
Do you have a family history of breast cancer? If yes, who had it and how old were they when diagnosed?

Use your best guess if you do not know or remember exact age.
Emergency Contact Information
Name of Contact*
Relationship with Contact*

Example: sister/brother, mother/father, aunt/uncle, family friend, personal friend, neighbor
Phone Number for Contact*
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 I am approved for services, I understand that any appointment changes, cancellations, or reschedules must be done through Libby's Legacy or I may be billed by the service provider.
Did you understand the statement?*
Electronic Signature
Typing your full name shall be considered as an original signature for all purposes and shall have the same force and effect as an original signature.
Signature*
First Name Last Name
Signature Date*

Mammogram Application (English)

Financial Information

Breast Health Information

Emergency Contact Information

Patient's Statement of Understanding

Electronic Signature

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