McLaren Cancer Institute > For Employees > Preventive Cancer Screening Incentive Form

Preventive Cancer Screening Incentive Form

Preventive Cancer Screening Incentive Form

Monthly drawings at the end of each month from February 2013 to July 2013.

  • 3 - $100 gift cards/ each month
  • 10 - $20 gift cards/ each month

To enter the drawing all you have to do is see your primary care physician during the months of Feb. 2013 - July 2013 (employees and their spouses are eligible) for a preventative screening procedure for breast cancer, cervical cancer, colon cancer, and or prostate cancer. Fill out the form below and click submit.

Eligible Screening Procedures include:
Breast – Mammogram
Cervical – Pap test with or without HPV testing
Colon – Colonoscopy and/or Sigmoidoscopy
Prostate – PSA blood test with or without a digital rectal exam

** Please remember that the procedures are to be preventative to be eligible, not diagnostic which means the physician has found something to warrant the procedure to be done. **

*Indicates required information

Name:*
Address:*  
City, State, Zip:*     
Phone Number:*
McLaren Subsidiary/Location:*
Dept./Unit Name:*
Procedure Performed:* 
Date of Procedure:*
Name of Physician:*
Physician's Phone Number:*  
Any questions please contact Mandie Zerka at 810-342-4519