Updated Enrollment Process and Form

Healthcare Provider

Wyoming Cancer Program defines a healthcare provider as a medical clinic, public health nursing office, free clinic, federally qualified health center, or radiology facility, etc.

New Enrollment Process

The Wyoming Cancer Program has updated the enrollment process for coverage for breast, cervical, and colorectal cancer screenings. Healthcare providers must now complete an enrollment form for patients who they are referring to the program. This new form collects the required information about each patient’s risk factors and previous medical history.

Any patient who does not have a healthcare provider may contact a program enrollment site at 1.833.660.2004 for assistance.

New Enrollment Form

Because the new enrollment process relies on information from the healthcare provider related to the patient’s medical history, the program has updated the enrollment form to gather the required information. The new forms are now available.

The program will fully transition to this new form on November 1, 2024, and older versions of the application will no longer be accepted after this date.

Updated Enrollment Forms

Spanish (only page 2 is in Spanish for patient convenience)