We've Got You Covered Mammogram Request | Huron Regional Medical Center

For more information about the program, click here.

First Name*

Last Name*

Address*

City*

Date of Birth*

Daytime Phone*

Have you had a mammogram in the last year? *

Yes

No

Do you have health insurance?*

Yes

No

If no health insurance, you may qualify for other programs which will provide other women’s health services. If you are comfortable with providing your income range, please select from the list:

Husband-wife combined income before taxes should be at or below levels listed for family size.
Single income before taxes should be at or below levels listed for family size.

If you have health insurance, do you know if your insurance covers a screening mammogram?*

Yes, they do cover

No, they do not cover

I do not know

If you do not know if mammograms are covered by your insurance, we can help you determine coverage by answering these questions about the insurance company.

Is your insurance provided by your or your spouse’s employer?

I'm the policyholder

My spouse is the policyholder

If insurance is with spouse's employer, what is your spouse's name?

Policyholder's Employer's Name

Insurance Company Name

Group Number

Policy Number

Insurance Company Contact Number

Our business office staff will check with your insurance provider to determine coverage. When would be a good time to call you back?

How did you hear about this program? (check all that apply)*