An official website of the State of Oregon
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Forms Valid 1/1/2021-Current
ScreenWise Final Outcome Form
Referral FormThis document is a new tool for referrals to services (including mammograms). This is not required, but a tool to support ScreenWise providers as we transition away from the voucher system.
Request for Clinical Exception FormIf you have a recommended procedure that is not on our CPT code list, you can use this form to request an exception.
Out-of-Pocket Agreement Form - English | Spanish
Next Steps & Program Participant Referral Stamps
All forms are in PDF format.
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