Interested in Getting a *No Cost* Colonoscopy, Mammogram, Pap Test, or Low-Dose CT?

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Harford County Health Department Cancer Prevention Services - Colorectal, Breast, Cervical and Lung cancer screenings at no cost for Maryland residents eligible for the program. Use this form to submit your interest in finding out if you are eligible.

Requirements:
• Be a current Maryland resident
• Have no health insurance OR have insurance with copays & deductibles
• Meet age requirements: Colorectal Cancer Screening - Men & Women aged 50 or older (or 18-49 with doctor referral); Breast Cancer Screening - Women aged 40 & older; Cervical Cancer Screening - Women aged 21 & older
• Meet income guidelines

If you are interested in enrolling, please fill out the form below and we will contact you to determine your eligibility.
Cancer Prevention Telephone Number: (410) 942-7930

First Name *

Last Name *

Phone Number *

Email Address

Age

Home Address

Provider (Name, Practice, and Phone Number)

If no health care provider, enter "none"

Which of our cancer screening's are you interested in? (Check all that apply) *

Mammogram (Breast - Age 40+) *MUST BE UNINSURED

Pap test (Cervical - Age 21+) *MUST BE UNINSURED

Colonoscopy (Colorectal - Age 50+)

Low-Dose CT (Lung - Age 55+) *MUST BE UNINSURED

Other:

Required

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