Screening Mammography Application Screening Mammography Application The inability to pay should not prevent you from receiving preventive care. If you are uninsured or underinsured, the United Cancer Support Foundation can assist you with getting a mammogram at no cost to you. To receive a quicker response, please answer all questions. If you have any questions, please give us a call at 865.474.1551. Funds are only available for mammograms (screening or diagnostic). (Note: This free service is currently not available in the following states: Michigan, Minnesota, New York, Iowa, Oregon, and Utah.) Name: Date of Birth Age: Gender Healthcare Coverage Yes No If covered, check one for type: Personal policy Employer policy Medicare Medicaid Home Address: City: State: Zip: Phone #: E-mail: Race and Ethnicity (Check one) Hispanic or Latino Black or African American Asian White American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Are you currently employed? Yes No Annual household income: Household Size: Emergency contact: Relationship to you History and Client Information Form 1. How did you hear about UCSF or American Breast Cancer Support Association? 2. Have you received a mammogram from UCSF or ABCSA in the past? YES NO If YES, When? What were the breast exam results? Normal Suspicious Other If OTHER, please specify: 3. Have you ever had a mammogram? YES NO If YES, when was your last mammogram? 4. Have you had a clinical breast exam in the last year? YES NO If YES, when? 5. *Please check if you have any of the following symptoms: Breast lump Discharge from nipple Pain Other If OTHER, please list symptoms: *If you have any of these symptoms, you need to have a doctor's order from your physician or local health department. 6. Do you have a history of cancer? YES NO If YES, what type and when? 7. Do you have a family history of cancer? YES NO If YES, who and what type? All information is confidential and used to determine eligibility. If approved, all payments are made directly to imaging and radiology providers. Submission of this application does not imply or guarantee approval of financial assistance. Applications are reviewed and evaluated to aid those with the greatest need. I declare that the information provided in this form is true and correct. I understand UCSF reserves the right to decline my application without explanation. I understand that typing my full name and date shall be considered as an original signature for all purposes and shall have the same force and effect as an original signature. Signature Date If you are human, leave this field blank. Submit