Healthy Lungs in Florida Screening Program Application

(ALL fields on this form are required.)

 

Personal Information

Address:
Ethnicity:
Gender at Birth:
Are you or have you ever served in the armed forces or been a firefighter?
Do you currently have a prescription for a Low-Dose CT Lung Cancer screening exam?

Criteria for Low-Dose Lung Cancer Screening CT Scan

(To qualify, you must answer True to all of the requirements below)

You are between 50 - 80 years old.
You have no signs or symptoms of lung cancer. (Ex: weight loss that is unexpected, shortness of breath, coughing up blood, etc.)
Either you currently smoke or have quit smoking within the past 15 years.
You have a 20 Pack-Year* smoking history.

*How to calculate your pack-year:
20 pack-year smoking history should be calculated off of when you smoked the most.
There are 20 cigarettes in one pack.  If you smoked 10 per day, that equals .5 pack.
(How many cigarettes you smoked per day / 20) x how many years you smoked = Your Pack Year

Other Medical Questions

Have you been diagnosed with lung cancer?
Have you ever been exposed to toxic substances?
Have you ever been advised by a healthcare professional to undergo lung cancer screening?
Are you a current smoker?
Have you been explosed to second hand smoke?

Financial Information

Declaration

I hereby declare that the information provided in this application is true and accurate to the best of my knowledge.  I understand that any false information may result in the rejection of my application. 

By agreeing to participate in this program, individual agrees to share information protected by the Health Insurance Portability and Accountability Act of 1996 (HIPPA) with the FLHC and the healthcare provider administering the scan. Additionally, information may be collected for research purposes with the aim of contributing to lung cancer screening awareness and furthering the mission of the FLHC. This information will not be shared outside of the FLHC and your provider.

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