1. State of Residence Make A Selection Alaska Alabama Arkansas American Samoa Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Marshall Islands Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Palau Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming  

2. Date of Most Recent Mammogram

a) Month Make A Selection January February March April May June July August September October November December  
b) Year Make A Selection 2001 2000 1999 1998 1997 1996 1995

3. Amount Doctor Charged You for Mammogram   $

4. Payment You Received From
Insurer     $

5. Name of Insurer. If your mammogram was covered by Medicare, answer "Medicare"

6. Does the cost of a mammogram discourage you from having this test? (check one)

 Yes  No  

7. Additional Comments  

If you have questions, please, contact us at mammography@healthcarechoices.org.