BreastCare New Provider Enrollment - Start Page

Welcome to ADH BreastCare New Provider Enrollment. Please review the information below, and then select 'Start a NEW Enrollment' or select 'Resume an Incomplete Previous NEW Enrollment Session' at the bottom of this page to begin.
Welcome to BreastCare New Provider Enrollment
Welcome to the Arkansas Department of Health's BreastCare New Provider Enrollment System. We welcome your expertise and assistance in helping us provide services to over 12,000 women in Arkansas. This Public Health Service Agreement (PHSA) will be effective July 1, 2013 thru June 30, 2015. All PHSAs received after June 30, 2013 become effective on approval date.
Before you start the enrollment process, please have all applicable documents ready:
  • NPIs for both group and individual providers
  • Group Tax ID number and individual providers social security number
  • Banking Routing and Account number
  • Individual Medicare number
  • Individual provider Arkansas Medical/Nursing License number and expiration date
  • Individual provider DEA Registration number and expiration date, if applicable
Please complete all the information requested. Once the online enrollment is successfully submitted, the ADH BreastCare program will review it for accuracy, and email the following documents to the contact person's email address listed on the agreement:
  • Public Health Service Agreement
  • Authorization for Automatic Electronic Funds Deposit (please attach a copy of a bank letter) (Attachment B)
  • Provider Name and Specialty Form (Physician/nurse groups, Community Health Centers (CHCs), and hospitals should complete this form for each clinic/group practice operating under this agreement) (Attachment E)
  • Provider Questionnaire (Attachment F)
When you receive the above documents, please print, sign and return them with original signatures along with the following:
  • Attachment A – BreastCare Policies and Procedures (will be available for print)
  • Attachment C – W-9 (including name you submit to IRS for 1099 and DBA name) (will be available for print)
  • Copies of Arkansas medical or nursing licenses, and DEA registrations if applicable, for each provider listed as an Individual Provider
  • Documentation of CMEs pertaining to breast or cervical cancer (CRNAs, anesthesiologists, CHCs and AHECs are exempt)
Send your completed packet to the following address:
Arkansas Department of Health
Attention: BreastCare Provider Management
4815 W Markham St, Slot 11, Little Rock, AR 72205
Additional Information
BreastCare requires providers to use their NPI in the Billing Provider field and in the performing or referring provider fields if applicable. For help in linking your NPI, please call the BreastCare Billing Analysts at 1-855-661-7830.
You will need to fax updated copies of each individual provider's Arkansas Medical or Nursing Licenses, and DEA Registrations (if applicable) prior to expiration to 501-661-2189, Attention BreastCare Provider Management.
The Provider Manual and reimbursement rates, considered part of this agreement, are available on the web at, under the Just for Providers section.
If you have any questions or concerns regarding this agreement, please call the numbers listed below.
Questions About: Contact Phone Number
NPI Reporting or Billing HP Enterprise Services 1-855-661-7830
Provider Enrollment or PHSA ADH BreastCare — Shiela Couch 1-800-462-0599, ext. 661-2836
  ADH BreastCare — Wanda Lung’aho 1-800-462-0599, ext. 661-2947