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Breast & Cervical Health Check Annual Screening Data Collection Form Clinic: Medical Record #: Last Name: First Name: Social Security #: Date of Birth: MI — Date of Exam: HISTORY — — CERVICAL
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What is alaska bchc enrollment form?
The Alaska BCHC Enrollment Form is a document used to enroll in the Alaska Breast and Cervical Health Check (BCHC) program, which provides free or low-cost breast and cervical cancer screenings to eligible individuals.
Who is required to file alaska bchc enrollment form?
Any individual who meets the eligibility criteria for the Alaska BCHC program and wishes to avail of the free or low-cost breast and cervical cancer screenings must file the enrollment form.
How to fill out alaska bchc enrollment form?
To fill out the Alaska BCHC enrollment form, you need to provide personal information such as your name, address, contact details, demographic information, and income details. You will also need to provide information about your medical history and previous screenings.
What is the purpose of alaska bchc enrollment form?
The purpose of the Alaska BCHC enrollment form is to collect necessary information from individuals who wish to participate in the program. This information is used to determine eligibility, provide appropriate screenings, and track program outcomes.
What information must be reported on alaska bchc enrollment form?
The Alaska BCHC enrollment form requires the following information to be reported: personal details (name, address, contact information), demographic information (age, gender, race/ethnicity), income details, medical history, and information about previous breast and cervical cancer screenings.
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