Get Title X (fp) Cervical Screening Form - Michigan Cancer Consortium - Michigancancer

Filling out the Title X Cervical Screening Form is an essential step for those seeking cervical cancer screening services. This guide provides clear, step-by-step instructions to ensure your form is completed accurately and efficiently.

Follow the steps to complete the cervical screening form online.

1. Click ‘Get Form’ button to obtain the form and open it in your document editor.
2. Begin by entering the referring Title X agency and agency phone number at the top of the form. This information helps to identify the agency that is facilitating your screening.
3. In the 'Client Information' section, carefully print your last name, first name, middle initial, and maiden name if applicable. Ensure that your details are clear and legible.
4. Provide your street address, apartment number (if applicable), city, state, ZIP code, and date of birth. Double-check that all information aligns with your identification documents.
5. Indicate your yearly family or household income and the number of people in your household. These details may be used for eligibility purposes.
6. Select your race from the options provided and indicate whether you identify as Hispanic or Latino. This information is important for demographic statistics and may assist in resource allocation.
7. Specify whether you have insurance, and if so, fill in the type of insurance, policy number, and group number as requested. Remember to fax a copy of the front and back of your insurance card to the designated office but keep it in your permanent medical file.
8. In the 'Pap Test' section, fill in the service date and the lab facility name where the Pap test was conducted. Indicate the type of Pap test performed by checking the relevant box.
9. Provide results regarding the Pap test's specimen adequacy and pelvic exam results. Specify if the Pap test results suggest any concerning findings by selecting the appropriate options.
10. If your Pap test results indicate a potential cervical cancer diagnosis, ensure you mark the relevant box, as only these cases are eligible for referral to the Breast and Cervical Cancer Control Program (BCCCP).
11. Complete the colposcopy date and provider site information if applicable. This is necessary for follow-up care.
12. Once all sections of the form are completed, review your entries for accuracy. You can then save any changes, download, print, or share the form as needed.

Complete the Title X (FP) Cervical Screening Form online today to ensure timely access to critical health services.