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Cayuga County, NY · Cayuga County

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CSP Screening Eligibility Form

This form collects client information to screen people for eligibility for the Cancer Services Program’s screening services.

At a glance

Issued by
City of Cayuga County · Cayuga County, Cayuga County, New York
Notarization
Not required: file this form without a notary.
Official source
cayugacounty.gov
Blank form
Download the PDF
Catalogued
Machine-readable
JSON record · about the forms index

What this form is

The CSP Screening Eligibility Form collects intake information to assess eligibility for the Cancer Services Program. It asks about age, insurance, household income, family history, prior screenings, and contact information; the form identifies an age range of 40–64. If the client meets the eligibility criteria, the form says to complete its back page.

Who needs it

People ages 40–64 seeking screening through the Cancer Services Program can provide the information requested for an eligibility assessment.

How to submit it

Fax the completed form to (607) 756-3419, as instructed at the top of the form.

About notarization

This form has no notary block; complete its date and intake fields, and it lists no attachment or related step requiring notarization.

How to submit this form

  1. 1

    Download the Form

    Download the CSP Screening Eligibility Form.

  2. 2

    Complete the Intake Questions

    Fill in the requested client, age, insurance, income, family history, and screening information.

  3. 3

    Complete the Back Page If Eligible

    If the client meets the eligibility criteria, complete the back of the form.

  4. 4

    Fax the Form

    Fax the completed form to (607) 756-3419, as directed on the form.

Frequently asked questions

Do I need a notary for the CSP Screening Eligibility Form?
No. The form has no notary block, and it lists no attachment or related step requiring notarization.
Who uses the CSP Screening Eligibility Form?
People ages 40–64 seeking Cancer Services Program screening can provide the requested information for an eligibility assessment.
What information does the form ask for?
It asks about age, insurance, household income, family history, contact information, and prior mammograms, Pap smears, and colon cancer screenings.
How do I submit the CSP Screening Eligibility Form?
Fax the completed form to (607) 756-3419, as instructed at the top of the form.

Need something notarized?

This CSP Screening Eligibility Form doesn’t need a notary, but if you have another Cayuga County form that does, a commissioned online notary can help.