Healthy Lungs in Florida Screening Program Application

 

To qualify for the Healthy Lungs in Florida screening program, you must meet the criteria listed above and all three of the following requirements:

  1. You are a resident of Florida, specifically near the Treasure Coast.
  2. You have a prescription from your physician.* If you do not have a prescription, we can assist you in obtaining one.
  3. You cannot afford the exam. No tax documentation is required, just a short application.

*If your doctor has recommended a diagnostic Chest CT exam, you will not qualify for this screening exam.

 

If you feel you meet the exam criteria and qualifications above, the process unfolds as follows:

  1. You complete the financial application.
  2. After your application is reviewed, a Florida Lung Health representative will contact you.
  3. If your application is approved, we'll provide you with a list of participating imaging centers and a voucher to pay for the exam.
  4. You schedule your exam at the most convenient time and location.

(ALL fields on this form are required.)

 

Personal Information

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 exposed to second hand smoke?

Financial Information

How did you hear about this opportunity?

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.