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ScreenWise Forms

Effective January 1st 2019, all ScreenWise providers will need to use the new form formats for all patients being newly enrolled or those being re-enrolled. For patients that were enrolled prior to January 1st 2019, providers will need to have their results and abnormal follow up recorded on the old/existing forms.

OLD Form cut off dates / NEW form implementation:

  • Monday, December 31st: last day to enroll using the old Intake Packet forms
  • Tuesday, January 1st: new forms go LIVE, all new enrollments must be completed using new forms on and after January 1, 2019
  • Monday, April 1st: all result and abnormal follow-up forms need to be submitted on new forms regardless of enrollment date

ScreenWise will be conducting training webinars on the new forms throughout the month of December. These webinars will all be identical but held at 7 different days and times to provide increased access. Please register for webinars here*. Audio/Video form tutorials are available on the ScreenWise Website​.


Optional Forms

Referral Form (pdf)
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 (pdf)
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 (pdf) | Spanish (pdf)

Next Steps & Program Participant Referral Stamps (pdf)

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