Lung Cancer Self-Referral

Are you eligible for lung cancer screening?

The following questions will be used to help assess whether you would be a candidate for this program. It will also be used to evaluate the services we provide and for other authorized purposes under the Health Information Act (HIA)IA)H. If you are a candidate, you will be asked to provide additional information (including your Alberta health care number) to register you for this program. A healthcare provider will follow up with you to obtain additional information to refer you to the Lung Cancer Screening Program. At times, non-identifying information may be disclosed to support quality assurance and quality improvement. The collection, use and disclosure of the information described above is authorized under sections 19, 20(b), 21(1)(a),27, and 32 of the HIA.

If you have any questions about the collection or use of the information or the completion of this form, please contact AHS Screening Programs at 1-866-727-3926 option 4.

If you’re not sure about screening but would like further information about the program, please visit our website at, speak to your healthcare provider, or speak with your family, and then call the ALCSP at 1-866-727-3926 option 4 if you would like to see whether lung screening is the right fit for you.