ScreenWise Forms

Operational Documents

• ScreenWise Program Operations Manual
• ScreenWise Enrollment and Data Reporting Requirements
• Secure Portal Instructions(required for all form submissions)
  
• 2024 EOB and PDR Schedule
• Provider Contact Update Form 
  

Enrollment and Results Forms

 Forms Valid 3/1/2024-Current

• ScreenWise Patient Enrollment Form(English)(Updated 11/2024)
  
• ScreenWise Patient Enrollment Form (Russian)
  
• ScreenWise Patient Enrollment Form (Korean)
  
• ScreenWise Patient Enrollment Form (Chinese)
  
• ScreenWise Patient Enrollment Form (Spanish)
  
• ScreenWise Patient Enrollment Form (Vietnamese)
  
• ScreenWise Results Form (Updated 10/2024)
  

• ScreenWise Final Outcome Form
  

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 a Clinical Exception
If you have a recommended procedure that is not on our CPT code list, you can use this form to request an exception.

All forms are in PDF format.