Primary insurance

What is the name of your primary insurance provider?

Policy ID number

Phone number on the back of your insurance card

Address or PO Box on the back of your insurance card.

Is your primary insurance a Medicare Advantage Plan? (Medicare Advantage is a type of Medicare health plan offered by a private company that contracts with Medicare.)

Who is your Primary Care Physician? (Medicare Advantage plans require authorization from your physician before processing; by providing this information, we can get authorization on your behalf.)

Is the patient the insurance holder?

Yes

No

Policy holder's first name

Policy holder's last name

Policy holder's date of birth

Policy holder's gender

Male

Female

What is the patient's relationship to the primary holder?

Does the patient have secondary insurance, or a Medicare Supplement (Medigap) Plan?

Yes

No

Secondary insurance company

Secondary insurance policy number

Phone number on the back of your secondary insurance card

Address or PO Box on the back of your secondary insurance card

Check to see if your employer is a Moffitt Connect Partner. Search and select your employer below. (Health information will not be shared with your employer.)

Trust Your Mammogram with the Experts

Annual Mammograms are Key to Women's Health

The Lifesaving Power of Early Detection Close to Home

Who Should Get a Moffitt Mammogram?

Some Women are at Higher Risk for Breast Cancer.

Prioritize Getting a Mammogram at Moffitt if:

Mammography Appointment Preferences

Mammogram Details

Patient Contact Information

Patient Insurance Information

Do you know your breast cancer risk?