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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:
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 https://attendee.gotowebinar.com/rt/8812127595217549827*. Audio/Video form tutorials are available on the ScreenWise Website.
Monday April 1st: All result and abnormal follow-up forms need to be submitted on new forms regardless of enrollment date
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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