Every Woman Counts (EWC) Manuals, Forms and Worksheets
Every Woman Counts (EWC) Step-By-Step Provider User GuideNote:
The Consent to Participate in Program will be available in other languages at a later date.
Notice of Privacy Practices Form
The Notice of Privacy Practices can be downloaded from the Notice of Privacy Practices page of the DHCS website in English and the following languages:
- Recipient Eligibility Form (DHCS 8699, English), EWC Recipient Eligibility Form Addendum, English
- Recipient Eligibility Form (DHCS 8699, Spanish), EWC Recipient Eligibility Form Addendum, Spanish
- Breast Cancer Screening Cycle Data Worksheet (DHCS 8709, color version)
- Cervical Cancer Screening Cycle Data Worksheet (DHCS 8710, color version)
Provider Data Request Form
- Enrollment and Recipient Cycles Data Request Form and Instructions (DHCS 8646, fillable PDF version)
- Breast Only Primary Care Provider Covered Procedures (DHCS 8471)
- Breast & Cervical Primary Care Provider Covered Procedures (DHCS 8472)
- Referral Provider Covered Procedures (DHCS 8473)
If you cannot view the MS Word or PDF (Portable Document Format) documents correctly, please visit the Web Tool Box to link to a download site for the appropriate reader.