Form H1550, Out of State NBCCEDP Verification

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Effective Date: 7/2015


Updated: 10/2007


To verify that a client was screened under the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) in another state.


When to Prepare

If a woman who moves to Texas indicates that she was screened through the NBCCEDP in another state, then send her the Form H2340. Once the completed H2340 is received, then send the Form H1550 to the NBCCEDP contact that the client provided on the Form H2340. Prepare Form H1550 to verify that the client was screened for breast and cervical cancer through the NBCCEDP in another state.


If the NBCCEDP contact does not return Form H1550 within 10 days after you sent the form, contact them to request the form be returned as soon as possible.

Form Retention

Keep a copy according to the retention requirements for case records. See the Manager's Guide for Eligibility Programs.

Detailed Instructions

The advisor

  • enters the patient's name, date of birth and Social Security number on the Form H1550
  • enter the patient's name in the space giving her permission for release of the requested information. She signs and dates the form in the spaces provided.

The NBCCEDP contact

  • completes the form;
  • signs and dates the form;
  • enters their name, address and telephone number; and
  • returns the form to the advisor.

When the form is received, ensure that the NBCCEDP contact signed and dated it.