Download the Recipients Eligibility Form Addendum 2026

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The document outlines the Every Woman Counts (EWC) Program by the California Department of Health Care Services, which, effective January 1, 2017, expands eligibility for breast diagnostic services to symptomatic individuals of any age, as per Assembly Bill 1795. It includes a recipient eligibility form addendum that requires individuals under 40 to indicate specific breast symptoms for service access.

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Click ‘Get Form’ to open the Recipients Eligibility Form Addendum in our editor.
Begin by reviewing the introductory section, which outlines the purpose of the form and relevant legislative context. This will help you understand the importance of providing accurate information.
In the section for symptoms, check all applicable boxes that describe your condition. If you have other symptoms not listed, please specify them in the provided space.
Once you have filled out your symptoms, proceed to sign and date the form at the bottom. Ensure that your signature is clear and matches your name.
If you are a provider completing this form, verify eligibility by signing and dating in the designated area for provider use only.

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2017	4.6 Satisfied (37 Votes)

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What is an eligibility form?

Eligibility Forms enable organizations to add an eligibility step in front of any initial form. Inserting a screening stage ahead of an application form will prevent ineligible applicants from proceeding and ensure that only qualified applicants will be able to continue to the main submission process.

What is a medical eligibility form?

A medical eligibility form is a document used by medical service providers to determine the eligibility for a patient to receive medical services.