Breast Screening Program Eligibility Questionnaire
First Name
Last Name
Date of Birth
Phone
Email
Verify/Retype Email
Zipcode
City/State
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
DC
AE
AA
AP
Household members (Adults 19 / Children 18 and below)
Adults 19+:
1
2
3
4
5
6
7
8
9
10
Children:
0
1
2
3
4
5
6
7
8
9
10
Total Household Gross income as reported on my most recent tax form and year
Can you pay your provider at time of service?
At the time of application (Not Now), Can you make the required $5.00 Pay-It-Forward-Contribution online? This contribution will assist others in need of UBCF services. (This is required.)
If the answer is no to any of the questions above, please provide a detailed explanation.
How did you hear about UBCF?
