Provider Forms and Manuals 

Providers: New Information | Professional Development | Forms & Manuals | Clinical Guidelines | Provider Enrollment |  Frequently Asked Questions

All documents are in PDF format unless otherwise noted.

BreastCare Manuals

BreastCare Provider Manual 
Provider Enrollment System Manual – Updated May 2013
Provider Re-Enrollment System Manual – Updated May 2013
Online Data Entry System User Manual  – Updated January 2014

Billing Information and Manuals

Billing Manual - Updated May 2017
Change to submission of electronic eligibility verifications and claims transactions
Claim Form | Updated March 2012
5010 Companion Guide  (Effective January 2012)
2017 Reimbursement Rates: Breast (Effective January 1, 2017)
2017 Reimbursement Rates: Cervical  (Effective January 1, 2017)
Application for WebRA Hardship Waiver
WebRA (Remittance Advice) - letter

Patient Care Forms and Procedures

Annual Verification of Treatment
Arkansas Tobacco Quitline Fax Referral Form – English | Spanish
Authorization for Prior Approval
Breast TNM Classification and Staging
Care Coordinator Referral Form
Cervical TNM Classification and Staging
Diagnostic Verification and Treatment Plan
BreastCare Resource Directory

Patient Education Forms

Know your choices for Routine Pap Testing: English | Spanish
Welcome to BreastCare – Covered and Non-Covered Services:  English  | Spanish

Provider Management Forms and Procedures

BreastCare Policies and Procedures
Authorization for Prior Approval
Authorization for Automatic Deposit Form (Attachment B)
Provider Information Change Form
Provider Name and Specialty Form | Instructions

County Health Department Forms

Mammogram Log
Pap Test Log

Free Software

HIPAA Complaint Software
Information About HIPAA Compliance Software