Cancer screening programs: the accounts of every woman

Cancer screening programs: the accounts of every womanMinistry of Health to pay for certain tests to detect breast cancer and / or cervical cancer, which can not afford these services. Most patients do not have cancer. For those few who, finding cancer early could save their lives. By signing this form means that you want to participate in cancer screening programs: All expenses of the woman. Will the next year, you will be contacted to be re-examined the leading provider of health care. Each http://www.medi-cal.ca.govyear, you must sign a consent form to participate. You can stop the program at any time.To participate, you must provide your name, address, date of birth, income, and some medical history. You must provide this information or not allowed to participate. It will ask for information such as social security number (if any), but should not be shown. The program has the right to collect and store information collected from you in this program in California law, taxes, and Section 30461.6, 42 USC 1501 and 45 CFR 160-164. All information will be protected as specified in the notice about cancer screening privacy policy, that authorization is given. Health and primary caregiver to give you the results that way. Health and primary caregiver to keep your medical records in a file and send medical records to find the section for use in cancer, and payment transactions in the areas of health, research, and in some cases to coordinate treatment. And you can share information with other programs of the Ministry of Health and other government agencies.The supplier may also share personal information with other health professionals to help you obtain the recommended services. We may disclose information when required by law, for purposes of workers' compensation. You have the right to inspect or obtain copies of records maintained by the Department of Cancer found that relates to your health, as specified in the notice of privacy.Your name will not be used in a report to the public. This may be a common name and date of birth, address, social security number with other providers in the program in order to avoid duplication of records.You will receive a copy of this consent to keep. Please talk to your primary health care if you have any questions.I gave (print) the information is accurate and complete and consent to participate in the Department of Public breast and / or detection of cervical cancer and screening program. I also agree to allow the use of personal data and medical, as described above. I understand that by signing this form, I consent to participate in the program during the year and participate in the program next year, I have to sign a new consent.Date of signatureI received a copy of the policy of cancer detection observed Privacy section.Date of signatureComplete only if the witness is required: I have read the information contained in this form, so that the patient mentioned above. I think the best of my knowledge and belief that the patient understands the information is ready to join the program and agree to the terms of this statement.Date of signatureCancer detection, MS 7203, PO Box 997377, Sacramento, CA 95899-7377(916) 449-5300 - (916) 449-5310 faxWebsite: www.cdph.ca.govCDPH 8478 (11/2011) in English / approval ...