PATIENT PERSONAL HISTORY OF CANCER (Check all that apply)
FAMILY HISTORY OF CANCER (Please indicate relationship, maternal or paternal, site of the cancer, and age at diagnosis. Indicate if bilateral, premenopausal, or triple negative breast cancer.)
** All information is required for review. Information provided is private and confidential. **
NOTE: These benefits are applicable only if the patient is an eligible enrolled member of a HealthChoice plan. All benefits are subject to the deductible,
coinsurance and policy provisions. Please verify benefits and eligibility by calling the medical claims administrator toll-free at 800-323-4314.
MEDICARE PATIENTS: If HealthChoice provides coverage that is supplemental to Medicare, all requested services must be approved by Medicare. The Medicare EOB should be filed for claims processing.