For Physicians
Breast Cancer Awareness, Inc. is committed to ensuring that uninsured individuals in our service area have access to essential breast cancer screening services. To better serve your patients, we’ve updated our waiver form and program guidelines. This program is specifically designed to cover the cost of a patient’s annual mammogram and, if necessary, a second “call-back” mammogram or ultrasound.
Please carefully review the following steps to ensure compliance and timely processing of imaging services. Your cooperation is crucial in helping us provide these vital services to those in need.
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Step 1
Physician verifies patient qualifies for the Mammogram Program. (See guidelines)
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Step 2
Physician fills out the waiver and has the patient sign the bottom “Patient Statement.”
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Step 3
Physician fills out “Pink Card” and refers patient to DIS or local imaging facility.
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Step 4
Physician faxes the signed waiver to BCA at 301-797-4090.
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Step 5
Patient makes mammogram appointment, takes pink card to the appointment, and the imaging facility bills BCA.
Forms MUST be faxed by referring physician’s office:
Fax 301-797-4090
12916 Conamar Dr.
Hagerstown, MD 21742
Patient Guidelines
- The program is only available for individuals that do not have insurance and
- Live in our service area (Frederick and Washington Counties in Maryland; Franklin and Fulton Counties in Pennsylvania; and Berkeley, Jefferson, and Morgan Counties in West Virginia).