ScreenWise Forms

Enrollment & Results Reporting Documents

• ScreenWise Program Operations Manual
• ScreenWise Enrollment and Data Reporting Requirements
• Secure Portal Access Instructions 
• 2023 EOB and PDR Schedule
• NEW* Enrollment & Results Contact Form 
  

ScreenWise Forms

 Forms Valid 1/1/2021-Current

• ScreenWise Patient Intake Packet - English 
  
• ScreenWise Patient Intake Packet (Russian) 
  
• ScreenWise Patient Intake Packet (Korean)
  
• ScreenWise Patient Intake Packet (Chinese)
  
• ScreenWise Patient Intake Packet (Spanish) 
  
• ScreenWise Patient Intake Packet (Vietnamese)
  
• ScreenWise Results Form
  

• ScreenWise Final Outcome Form

Form Tutorials

• 2022 ScreenWise Intake Packet with REALD Tutorial
• 2022 ScreenWise Result Form Tutorial
• 2022 ScreenWise Final Outcome Form Tutorial
  

Optional Forms

Referral Form
This 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 Form
If 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.