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TOBACCO SCREENING UNINSURED CLIENT REFERRED FOR INSURANCE mark all that apply Screened Positive. agency faxed referral Screened Negative Medicaid Other Client was not screened Connect for Health Colorado Client not referred PATIENT INSTRUCTIONS Please fill in each part below. Information is required for enrollment into the Women s Wellness Connection program. LAST NAME FIRST NAME IDENTIFICATION LAST 4 NUMBERS OF YOUR SOCIAL SECURITY NUMBER MIDDLE NAME MAIDEN NAME DATE OF BIRTH AGE WHAT...
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How to fill out womens wellness connection
How to fill out womens wellness connection
01
To fill out Women's Wellness Connection, follow these steps:
02
Begin by visiting the Women's Wellness Connection website or office.
03
Obtain the necessary forms and documents required for enrollment.
04
Complete the personal information section, including your name, address, phone number, and demographic details.
05
Provide information regarding your health history, including any past illnesses, surgeries, or medications you are currently taking.
06
Answer the questions related to your sexual and reproductive health, such as menstrual cycle, pregnancy history, and contraception usage.
07
Make sure to provide accurate and detailed information to ensure appropriate healthcare services.
08
Review the completed form for any errors or missing information.
09
Submit the form online or return it to the Women's Wellness Connection office.
10
Await further communication or contact the office to confirm the submission and inquire about next steps.
Who needs womens wellness connection?
01
Women's Wellness Connection is meant for women who meet certain criteria:
02
- Women between the ages of 21 and 64.
03
- Women with limited or no health insurance.
04
- Women who have not had a Pap test in the past three years or a mammogram in the past two years.
05
- Women who meet income requirements based on household size.
06
- Women who are in need of reproductive health services.
07
If you fulfill these criteria, you might be eligible for the services provided by Women's Wellness Connection.
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What is womens wellness connection?
Womens Wellness Connection is a program that provides free breast and cervical cancer screenings for eligible women in Wisconsin.
Who is required to file womens wellness connection?
Women who meet the eligibility criteria for the program are required to file for Womens Wellness Connection.
How to fill out womens wellness connection?
To fill out Womens Wellness Connection, eligible women need to contact their healthcare provider or local health department to schedule a screening appointment.
What is the purpose of womens wellness connection?
The purpose of Womens Wellness Connection is to increase access to breast and cervical cancer screenings for women who may not otherwise be able to afford them.
What information must be reported on womens wellness connection?
Information such as personal demographics, medical history, and screening results must be reported on Womens Wellness Connection.
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