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UNC REX HEALTHCARE MOBILE MAMMOGRAPHY ASSISTANCE PROGRAM CRITERIA The REX Mammography Assistance Program is designed to help uninsured women, who do not qualify for CCCP, in our surrounding areas in

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How to fill out request form mobile mammography

01

Start by downloading the mobile mammography request form from the official website.

02

Carefully read through the instructions provided in the form.

03

Fill in your personal details such as name, address, contact information, and date of birth.

04

Provide relevant medical information, including any previous breast surgeries or medical conditions.

05

Indicate your preferred examination date and time slot based on the available options.

06

If you have a physician referral, attach it with the form. If not, check whether one is required.

07

Review all the filled information and make sure it is accurate and complete.

08

Submit the filled request form through the designated submission method, such as email or fax.

09

Keep a copy of the completed form for your records.

10

Wait for confirmation from the mobile mammography service regarding your appointment.

Who needs request form mobile mammography?

01

Any individual who wishes to undergo a mobile mammography screening needs to fill out the request form.

02

This may include women who are due for routine breast cancer screenings or those who have symptoms or risk factors that require mammogram evaluation.

03

Medical professionals, such as doctors or nurses, may also need to fill out the request form on behalf of their patients.

04

It is important to consult with a healthcare provider to determine if a mobile mammography screening is appropriate for your specific situation.

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What is request form mobile mammography?

Request form mobile mammography is a form used to schedule a mobile mammography unit to provide breast cancer screenings at a specific location.

Who is required to file request form mobile mammography?

Medical facilities, clinics, or organizations that want to host a mobile mammography unit at their location are required to file the request form.

How to fill out request form mobile mammography?

The request form typically requires information such as contact details, desired date and location for the screening, number of expected participants, and any specific requirements.

What is the purpose of request form mobile mammography?

The purpose of the form is to coordinate the scheduling of a mobile mammography unit to provide convenient breast cancer screenings to underserved communities or organizations.

What information must be reported on request form mobile mammography?

Information such as contact details, desired screening date and location, expected number of participants, and any specific requirements for hosting the mobile mammography unit.

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