Women’s Preventive Health Services (WPHS) and
Breast and Cervical Health Program (BCHP)
Referral Form
Name:______
Age:______Contact phone number: ______
Preferred appointment site: ______Language: ______
Preferred appointment day & time: ______Good time to contact: ______
Do you have health insurance? Yes (______) No Unknown
Family size and income (see back): eligible (to be confirmed) not eligible (to be confirmed)
You may be eligible for a free/low cost women’s health exam with mammogram and Pap test.
BCHP is for women who:
♦ Are 40 to 64 years old
♦ Are 65 years old or older with no Medicare and/or Medicaid benefits
♦ Have limited income
♦ Have no insurance or limited insurance (deductible more than $ 500.00).
BCHP exam includes following services:
Check: height, weight, and blood pressure Women’s physical exam, including breast exam
Breast self exam education Hormone therapy consultation
Pelvic exam and Pap smear, if needed Mammogram
Referral services for abnormal breast and cervical test results
If needed, ICHS waives fees for the wet mount, gonorrhea, and chlamydia tests
When you go to your appointment, do not forget to:
Bring your ID, Social Security and insurance cards.
Bring proof of income. Check in 30 minutes early.
NOT ALL LAB TESTS, SERVICES, AND PRESCRIPTIONS ARE COVERED BY THE BCHP PROGRAM.
YOUR PROVIDER MAY REQUEST EXTRA TESTS NOT INCLUDED IN THE BCHP EXAM AND YOU MAY BE BILLED. YOU CAN APPLY FOR A SLIDING FEE DISCOUNT FOR NON-BCHP LAB TESTS AND SERVICES.
Annual exams cannot be done during menstruation.
Referred by:______Appointment Time and Date:______
Community Advocate: Please make a copy for the patient. Route original to PSR/EW Lead for scheduling.
International District Medical & Dental Clinic: (206) 788-3700
ID Clinic Scheduling Line: (206) 788-3763
Holly Park Medical Dental Clinic: (206) 788-3500
PSR/EW Lead: If scheduled, return completed form to WPHS Coordinator
If not scheduled, return form to Community Advocate for follow up.
Office Use Only
Date Form Received:______
Time/Date - 1st Call______Outcome: ______
Time/Date - 2nd Call______Outcome: ______
Time/Date - 3rd Call______Outcome: ______
Revised 10/08/07