From RECP Form, 2021
Some states have cancer registries which maintain records of individuals who have had cancer
diagnosed in that state. For your convenience, the Radiation Program has made arrangements with the following six states that have such registries. If the person who became ill with lung cancer was diagnosed with that disease in any of the following states and you wish to have the Radiation Program contact that state's registry to confirm a diagnosis of this cancer, please mark the box next to the appropriate state. You will also need to complete and sign the medical release on page 14.
• Arizona
• New Mexico
• Colorado
• Utah
• Nevada
• Wyoming