Arkansas Department of Health

• Home
• Prevention & Healthy Living
• BreastCare Program
• BreastCare Providers
• BreastCare Provider Forms and Manuals

BreastCare Provider Forms and Manuals

Provider, Billing Forms, and Manuals

• Provider Manual - updated April 2020
• 2021 Reimbursement Rates: Breast
• 2021 Reimbursement Rates: Cervical
• BreastCare Billing System User Access Form
• Billing Manual- updated February 2021
• BreastCare Claim Form

 

Patient Care Forms

• Be Well Arkansas: Quit Tobacco
• 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
• What You Should Know About Breast and Cervical Cancer: English | Spanish

 

Provider Management Forms

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