first american - breast cancer SCREENING EVENT

WEDNESDAY, OCTOBER 9, 2019 9:00 AM - 4:00 PM

1 First American Way,
Santa Ana, CA 92707

Alinea coach will be parked outdoors

qualifications 

FREE MAMMOGRAMS for women 40+ who meet the following criteria:

  • Low income

  • Uninsured

  • No other breast symptoms

We also accept the following insurances:

  • Aetna PPO

  • Blue Cross PPO

  • Blue Shield PPO

  • Cigna PPO

Mobile Mammography

Please fill out the following information to schedule your mammogram. Our staff will contact you within 2 business days to confirm your appointment time.  Prior to your appointment, please prepare the following:

  • Download and fill out the necessary patient paperwork

  • Bring a valid photo ID and Insurance Card if applicable

  • If you have had any prior mammograms at another facility, please bring them with you for comparison purposes.

PRIVACY: This is a secure site, all information remains confidential, federal (HIPAA) and state privacy law compliant AND will not be shared for any other purposes other than intended e.g. breast cancer screening as requested.

Appointment Form

PATIENT INFORMATION
Name *
Name
Date of Birth *
Date of Birth
Enter your date of birth in MM/DD/YYYY format
Phone # *
Phone #
Where can we reach you to verify appointment / insurance information?
Your exam should take an average of 15 minutes. Please select a preferred start time between 9am-4pm. If your preferred time is not available, our office staff will call you to offer alternate times. There will be no screenings between 12:00 - 12:30 PM due to staff's lunch break
Mammography Information
Are you a female over 40? *
Screening Mammograms are typically covered by Insurance if you are over 40 years. If you are under 40, we will have to verify with your insurance plan if you are covered for a mammogram exam. Please provide insurance information below for eligibility and verification purposes.
Has it been at least one year since your last mammogram? *
Do you have breast implants? *
Breast implants require additional screening time, and Alinea will have to make sure to schedule you appropriately.
INSURANCE / PAYMENT INFORMATION
Our staff will need your photo ID and insurance card on the day of the event. If you are self-pay, please bring a Credit Card with you.
If none, write n/a Providing your member ID at the time of registration will help us verify your insurance and eligibility prior to your mammogram screening appointment.
If you marked "OTHER" in the insurance section, please input your insurance plan along with your member ID # here. Thank you.