Recipients eligibility form addendum

1 State of california department of health care services health and Human services Agency department of health care services Every Woman Counts (EWC) Program RECIPIENT eligibility FORM addendum . Effective January 1, 2017, EWC provides breast diagnostic services to symptomatic Recipients of any age in accordance with Assembly Bill (AB) 1795 (Atkins, Chapter 68, Statutes of 2016). Please see the following link for the full bill text: Prior to January 1, 2017, EWC provided diagnostic services to women age 40 and older who presented with symptoms and/or signs of breast cancer. AB 1795 enables EWC to provide diagnostic services to symptomatic indivduals of any age. If you are under age 40, please indicate whether you have one or more of the following symptoms: Palpable mass, lump or swelling in the breast or the underarm.

2 Changes in size or shape of the breast;. Changes in skin texture and color (dimpling, puckering, redness, scaliness, or thickening) of the breast or nipple;. Nipple retraction or inversion;. Nipple discharge; and/or Other: change or feeling of the breast _____. I certify that the above information is true and correct to the best of my knowledge: _____ _____. Recipient Signature Date PROVIDER USE ONLY eligibility Checklist In addition to eligibility Checklist please verify that the recipient is under age 40 and has one or more of the symptoms listed above. _____ _____. Primary care Staff Signature Dat