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The Joint Commission

RETURN TO PRESS RELEASES 2011

Application for Free Mammogram through Susan G. Komen Foundation


Shay Nanke September 30, 2011

Project Hope

Eligibility Request

I hereby request Arkansas Methodist Medical Center to make a determination of my eligibility for the Project Hope Program:

 

Patient Name: _______________________________________________________________________

 

Date of Birth: _______________________________________________________________________

 

SSN: ______________________________________________________________________________

 

Address: ___________________________________________________________________________

 

Telephone: _________________________________________________________________________

 

Have you had a mammogram in the last year? YES/NO

Are you currently having any breast symptoms?   YES/NO   ______________________________________

Do you currently have any type of medical insurance coverage? YES/NO

Do you currently have a family physician?      YES/NO

Do you have a doctor’s order for a screening or diagnostic mammogram? YES/NO

Number of people in household_____________Total household income for prior (3) months: $_________________

 

• I affirm the above information I have supplied to Arkansas Methodist Medical Center is true

and correct to the best of my knowledge.

• I understand that I may be asked to provide income verification information.

 

Signature: _____________________________Date: _________

 

****FOR AMMC USE BELOW THIS LINE****

______________________________________________________________

Approved: ________Disapproved: _________

 

Signature: _____________________________

 

 Date: ________________________________



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RETURN TO PRESS RELEASES 2011