Open Enrollment

*Are you Latina/Hispanic: *How did you hear about this program? *Do you Smoke, Vape, or Chew Tobacco? *Most recent Pap Test you had was: *Most recent Mammogram you had was:

*Have you ever had a Hysterectomy?

Was the hysterectomy for cervical cancer?

Do you still have part of your cervix?

*Medicaid/Denali Care?

Medicaid #:

*Do you have MaineCare (Medicaid)?

Medicaid Option
(Select all that apply)

*Health Insurance:

Company & ID:

Insurance Name

Name of Policy Holder

SSN of Policy Holder

Policy Number

Provider:

My Current Provider

Have you faced any of the following barriers to getting breast and/or cervical screening?:
(Select all that apply)

Comments/Notes

Is there anything you think MBCHP should know?

* Please Select One

I am a provider or healthcare staff, completing an application with or for a patient

I am the poteneial client completing the application myself

MBCHP Staff

I am currently enrolled or have been previously

Provider:

Eligibility Information

*Date of Birth:

FPL Eligibility Status

Enrollment Information

Contact Information

Demographic / Healthcare Information

*Race:

Medicaid Option
(Select all that apply)

Have you faced any of the following barriers to getting breast and/or cervical screening?:
(Select all that apply)

Comments/Notes

* Please Select One

Open Enrollment

Eligibility Information

*Date of Birth:

FPL Eligibility Status

Enrollment Information

Contact Information

Demographic / Healthcare Information

*Race:

Medicaid Option (Select all that apply)

Have you faced any of the following barriers to getting breast and/or cervical screening?: (Select all that apply)

Comments/Notes

* Please Select One

Medicaid Option
(Select all that apply)

Have you faced any of the following barriers to getting breast and/or cervical screening?:
(Select all that apply)