Utah Breast and Cervical Cancer Screening Program Enrollment Form
NOTE: This form is also available in Spanish. To switch languages, select the "English" button located in the upper-right corner of the form.
The Breast and Cervical Cancer screening program is provided by the Utah Department of Health and Human Services and paid for with state and federal funding. We collect some personal and medical information from you and your medical providers when you agree to participate in the program.
Federal and state laws protect the information we collect, create, or keep about you. Your information will be kept secure. We will not give it to others without your consent, or as allowed or required by law. You don't have to give us any information. However, you may not be able to get services from the program if we don't have enough information to see if you qualify.
How will you use my information?
- To find out if you qualify for the program.
- Help you get screening and diagnostic follow-up services.
- Help connect you to resources to support your treatment (if needed).
- Remind you about upcoming screenings and tell you about other program opportunities.
- Send you reminders by text, email, or mail.
- Manage and evaluate the program.
What type of information will you collect about me?
You give permission for your doctors and other participating service providers to give us the following information when you sign up for the program:
- Personal information (including your name, date of birth, address, and phone number).
- Contact information for your doctors and other health care providers.
- Medical information collected while you participate in the program.
- Information related to the cost of procedures and services.
You also give us permission to share information we have about you with healthcare providers and doctors involved in your medical care and with the Utah Cancer Registry.
You give us permission to share this information to the Department of Workforce Services if you need more additional coverage for treatment.
Can I cancel my permission?
Yes. You can leave the program at any time. You must send a letter to the Breast & Cervical Cancer Screening Program to cancel your permission. The letter must include:
- The date
- Your name
- Your date of birth
- A statement in writing that says you want to cancel your permission to release your information
- Your signature
You will no longer be enrolled in the program if you cancel your permission. This means you may have to pay for any outstanding medical costs for any services you got while you were in the program- if you cancel your permission before everything is paid.