Native Women's Wellness Program (NWWP) Request for Travel Assistance

Welcome!

The NWWP helps to pay for the cost of breast and cervical cancer screenings for women who are eligible to enroll in the program. Women who are eligible to enroll in the NWWP can receive assistance with travel to screening and/or diagnostic appointments when they report a barrier or hardship related to travel.

The information being asked below will be used to determine your eligibility for enrollment into the NWWP. If you are not currently enrolled into the NWWP, we will refer you to our local Patient Navigator at the clinic to assist you with enrolling. Once enrolled, you will be able to receive travel assistance through the NWWP. Please note: You must be enrolled into the NWWP to receive additional assistance.

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* 1. By completing this form, I agree to be contacted by the SPIPA Cancer Programs staff and/or NWWP Patient Navigator who may ask for additional information in order to provide enrollment and/or travel assistance.

Yes

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* 2. Contact information

Name (Last, First) *

Date of Birth

Address *

City *

State *

ZIP/Postal Code *

County *

Email Address *

Phone Number *

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* 3. It is hard for me to afford or plan travel to my cancer screening/treatment appointments.

Yes

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* 4. What is your gender?

Female

Two- Spirit

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* 5. Please select the clinic where you receive care.

Chehalis

Squaxin

Nisqually

Shoalwater Bay

Skokomish

Other (please specify)

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* 6. Do you have health insurance?

Yes

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* 7. If you answered yes to the question above, please select your insurance. (Select all that apply)

Medicare/ Medicaid

Tribal Purchased Preferred Care

Private Insurance (please specify)

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* 8. How many people live in your household.

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* 9. Please provide your gross annual income

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* 10. Please select the type of cancer screening you will be receiving? (Select all that apply)

Screening Mammogram

Additional Imaging

Breast MRI

Breast Ultrasound

Cervical (HPV test/Pap smear)

Other (please specify)

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* 11. Please provide the date of your appointment or the date you were referred if your appointment has not been scheduled yet.

Referral

Date

Appointment

Date

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* 12. How many $25 cards are you requesting? The NWWP can provide up to 4 cards per person per program year. A new Travel Assistance Survey must be filled out for each appointment.

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* 13. Which gas station is most convenient for you?

Fred Meyer

Safeway

Either

Native Women's Wellness Program (NWWP) Request for Travel Assistance

Welcome!

Question Title

* 1. By completing this form, I agree to be contacted by the SPIPA Cancer Programs staff and/or NWWP Patient Navigator who may ask for additional information in order to provide enrollment and/or travel assistance.

Question Title

* 2. Contact information

Question Title

* 3. It is hard for me to afford or plan travel to my cancer screening/treatment appointments.

Question Title

* 4. What is your gender?

Question Title

* 5. Please select the clinic where you receive care.

Question Title

* 6. Do you have health insurance?

Question Title

* 7. If you answered yes to the question above, please select your insurance. (Select all that apply)

Question Title

* 8. How many people live in your household.

Question Title

* 9. Please provide your gross annual income

Question Title

* 10. Please select the type of cancer screening you will be receiving? (Select all that apply)

Question Title

* 11. Please provide the date of your appointment or the date you were referred if your appointment has not been scheduled yet.

Question Title

* 12. How many $25 cards are you requesting? The NWWP can provide up to 4 cards per person per program year. **A new Travel Assistance Survey must be filled out for each appointment. **

Question Title

* 13. Which gas station is most convenient for you?

* 12. How many $25 cards are you requesting? The NWWP can provide up to 4 cards per person per program year. A new Travel Assistance Survey must be filled out for each appointment.