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Home
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For Applicants
For Providers
More Info
Contact
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Youtube

Apply

You may be eligible for free breast and cervical cancer screenings!

Eligibility Basics

Do you live in Ashtabula, Carroll, Columbiana, Cuyahoga, Geauga, Harrison, Holmes, Jefferson, Lake, Lorain, Mahoning, Medina, Portage, Stark, Summit, Trumbull, Tuscarawas or Wayne County?
Are you between 21 and 64 years of age?
Are you without health insurance?
Do you have a limited income?

Downloadable PDF

Get Started Below

Step 1 of 3

33%

Contact Information
Name*
First Middle Initial Last Maiden Name (If applicable)
County of Residence*
Residential Address*
Street Address Address Line 2 City State ZIP Code
Phone Number*

Demographic Information
Date of Birth*
Age today*
Please enter a value between 10 and 100.
Social Security Number*
Ethnicity*
- Hispanic or Latino
- Non-Hispanic/Latino
Race*
- American Indian
- Asian
- Black
- White
Optional (used for program evaluation only) - check all that apply
- Amish
- Mennonite
- LGBTQ
- A woman with a disability
Number of people in household*
Please enter a value between 0 and 20.
Are you married?*
- Yes
- No
Spouse's Name
First Last
Monthly household income before taxes*
Income includes salary and wages, tips, alimony, public assistance, unemployment, Social Security, SSI, interest, retirement and pensions.

Medical Information
What medical coverage do you have currently?*
- No Insurance/Uninsured
- Medicare Part A
- Medicare Part B
- Medicaid
- Private Insurance, Employee Insurance, HMO
- Other - Disability, cancer policy, etc.
Please check all that apply.
How did you hear about My Body Matters or the Breast and Cervical Cancer Project for this enrollment?*
- My Doctor
- Social Media (Facebook/Pinterest/YouTube)
- At an Event
- I Received a Post Card in the Mail
- Other Organization (Komen, Community Agency, Etc.)..
- My Own Research
- Friend/Family Member
- TV/Radio/Newspaper
- BCCP Reminder
- Internet (Website/Search Engine, Etc.)
- Brochure/Flyer/Poster
- Heard a Speaker at...
- Other...
Please check one.
Please describe where you heard about us
Have you ever had a mammogram?*
- Yes
- No
Date of last mammogram
MM
DD
YYYY
Have you ever had a pap test?*
- Yes
- No
Date of last pap test
MM
DD
YYYY
Do you use tobacco?*
- Yes
- No

Apply today to see if you're eligible for free screening services.

This work is funded either in whole or in part by a grant awarded by the Ohio Department of Health, Bureau of Health Promotion, Breast and Cervical Cancer Project and as a sub-award of a grant issued by Centers for Disease Control and Prevention (CDC) under the Cancer Prevention and Control Programs for State, Tribal and Territorial Organizations grant, grant award number 6 NU58DP003936-04-02, and CFDA number 93.283.

Cuyahoga County Board of Health
5550 Venture Drive
Parma, Ohio 44130

Phone: 216-201-2062
Hot Line: 1-800-443-2168

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©2021 My Body Matters

Important Notice

As of March 30, 2020 the Cuyahoga County Board of Health no longer monitors this website. The Breast and Cervical Cancer Project (BCCP) program has transitioned from the Cuyahoga County Board of Health to the Fulton County Health Department. Please call 419-335-3907 for service. Thank you.