BREAST HEALTH PORTAL REGISTRATION

By providing the information requested below, your organization will be listed on the Breast Health Portal (www.BreastHealthTexas.org), an online resource of breast health providers and data. Only nonprofit organizations will be listed on the Breast Health Portal. To join as a Collaborative member, either individually or as an organization, click here.

Name: Job Title:

Organization/Clinic:

Street Address:

City, State, Zip:

Phone: Appointment Phone (if applicable):

Fax:

Email address:

County:

Counties Served (if applicable):

Website:

Brief description of the mission or services provided:

If you offer any services, programs, or payment options (Medicaid/Medicare, reduced cost, payment plans, etc.) for the low-income and/or under-/uninsured, please explain:

Organization Type (select one) City Clinic County Clinic FQHC or FQHC look-alike Hospital District Nonprofit Hospital Nonprofit Agency

Types of Services - Select all that apply:

Education Support Resources Screening Diagnosis Treatment

Yes, you have my permission to link from the Portal to my organization's website.

Yes, please include me as a member of the Breast Health Collaborative of Texas. (Membership is free - click here to see benefits)

My organization has more than one physical location.

For more information on Membership, contact Lyn Widlaski at lwidlaski@therose.org ● 281.464.5334
For more information on the Breast Health Portal, contact Lyn Widlaski at lwidlaski@therose.org ● 281.464.5334 OR Jeanne Hanks at jhanks@sleh.com ● 832.355.4460