SCREENING FORM Mammogram/Pap Test Screening Results ... - michigancancer 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your enrollment site and the date you enrolled into the program. Fill in your last name, first name, and birth date accurately.
3. Indicate your age and circle whether the mammogram, ultrasound, or pap test results were obtained from a non-BCCCP provider. Also, specify if you have a copy of the test results.
4. For mammography, select whether it is a screening or diagnostic type and provide the referral date to BCCCP.
5. Complete the ultrasound section by entering the date performed and facility name. Indicate if any follow-up is required based on results.
6. Fill out the pap test section with details such as date obtained and facility. Mark adequacy status and follow-up procedures as necessary.

Start using our platform today for free to streamline your form completion process!