Open Enrollment

*Are you Latina/Hispanic: *How did you hear about this program? *Do you Smoke, Vape, or Chew Tobacco?

Are you Homeless?

Do you drink alcohol?

Have you ever been pregnant or given birth?

Have you received the HPV vaccine?

Do you have a family history of breast, cervical, or other cancers?

Have you been diagnosed with cancer of any form?

Did you receive treatment?

*Have you ever had a Pap Test?

*Most recent Pap Test you had was:

*Have you ever had a Mammogram?

*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 preferred county for doctor visit is (unknown will get all providers):

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

Have you had any breast or cervical health services in the last 90 days? If yes, tell us in the note area what services you had, where had it and the date.

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 potential 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)