Get Illinois Breast And Cervical Cancer Program Screening Summary/office Visit Provider Information

This guide provides step-by-step instructions for completing the Illinois Breast and Cervical Cancer Program Screening Summary/Office Visit Provider Information form online. By following these directions carefully, you will ensure that all necessary information is accurately submitted.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the document and open it for editing.
2. Begin by filling out the lead agency information section. Enter the agency's name and the Cornerstone number as required.
3. Complete the date of the office visit and the birth date of the patient in the specified format (mm/dd/yyyy).
4. Indicate whether the patient is new or established by selecting the appropriate option.
5. Select the type of office visit that occurred by marking the checkbox that corresponds to the examination type performed (e.g., office visit for breast exam, pelvic exam).
6. Check the boxes for comprehensive client education that was provided, such as breast self-exam instruction and other relevant education.
7. For the clinical breast exam, provide the date conducted, indicating if it was not done, refused, or if the exam resulted in normal or abnormal findings.
8. For the pelvic exam, again indicate whether it was needed, refused, or not reimbursed. Record the date and select the appropriate outcome.
9. Complete the pap test section if applicable, indicating the absence of cervix if necessary and including the date.
10. Note if any diagnostic follow-up is required and provide details if applicable.
11. For specimen type, select the relevant option based on the test conducted and indicate specimen adequacy.
12. Fill out the pap test screening results, checking the relevant outcome from the list.
13. Document the date when the patient was notified of the results.
14. In the provider notes section, include any significant comments or recommendations for the patient.
15. Complete the cervical follow-up recommendations based on the test results and check the relevant options.
16. If applicable, check the box indicating the indication for the pap test and provide additional details.
17. Finally, ensure the provider or case manager signs and dates the form for validation.
18. After completing the form, save your changes, and download or print a copy or share it as needed.

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