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Breast Cancer Screening Exclusion Form Member Name: Member ID#: Date of Birth: This member has had a bilateral mastectomy or two unilateral mastectomies. Date of Bilateral Mastectomy: OR Date of First
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How to fill out breast cancer screening exclusion
How to fill out breast cancer screening exclusion:
01
Begin by carefully reading the instructions on the form. Make sure you understand the purpose and requirements of the breast cancer screening exclusion.
02
Provide accurate personal information, such as your name, address, contact details, and any identification numbers required.
03
Specify the dates for which you are requesting the breast cancer screening exclusion. This could be a one-time exclusion or a period of time, depending on your circumstances.
04
Clearly state the reason for requesting the exclusion. This could include medical reasons, personal beliefs, or any other valid justification.
05
If applicable, provide any supporting documentation or evidence to support your request. This may include medical records, doctor's notes, or any other relevant information.
06
Review your completed form for any errors or omissions before submitting it. Ensure that all sections are properly filled out and signed.
07
Submit the filled-out form through the designated channels specified in the instructions. This could involve mailing it, handing it in personally, or submitting it online, depending on the requirements.
Who needs breast cancer screening exclusion?
01
Individuals who have already undergone breast cancer screening within a certain time frame may request an exclusion to avoid unnecessary repeated screenings.
02
People who have a medical condition or previous medical history that could make breast cancer screenings problematic or uncomfortable may need to request an exclusion.
03
Individuals who may have personal beliefs or cultural reasons that prevent them from participating in breast cancer screenings may seek an exclusion.
04
It is important to consult with medical professionals or relevant authorities to determine if you meet the criteria for a breast cancer screening exclusion and to discuss the potential implications or risks associated with it.
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