Arkansas Department of Health

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BreastCare Provider Forms and Manuals

Provider, Billing Forms, and Manuals

• Provider Manual - updated April 2020
• 2020 Reimbursement Rates: Breast
• 2020 Reimbursement Rates: Cervical
• BreastCare Billing System User Access Form
• Billing Manual- updated February 2019
• BreastCare Claim Form

 

Patient Care Forms

• Be Well Arkansas: Quit Tobacco Fax Referral Form
• Prior Authorization Form
• Regional BreastCare Coordinator Referral Form

 

Patient Education and Handouts

• Know Your Choices for Routine Pap Testing: English | Spanish
• Welcome to BreastCare – Covered and Non-Covered Services:  English | Spanish

 

Provider Management Forms

• Authorization for Automatic Deposit Form
• Provider Information Change Form
• Provider Name and Specialty Form