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. We appreciate your expertise and assistance in helping us provide services to women in Arkansas. This Public Health Service Agreement (PHSA) will be effective July 1, 2017 thru June 30, 2019. All PHSAs after June 30, 2017 become effective on approval.
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 provider's social security number
  • Banking Routing and Account number
  • Individual provider Arkansas Medical/Nursing License number and expiration date
  • Individual provider DEA Registration number and expiration date, if applicable
  • Individual provider Medicare number, 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 listed on the agreement:
  • Public Health Service Agreement
  • BreastCare Policies and Procedures (Attachment A)
  • Authorization for Automatic Electronic Funds Deposit (please attach a copy of a bank letter) (Attachment B)
  • W-9 (including name you submit to IRS for 1099 and DBA name) (Attachment C)
  • 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 D)
  • Provider Questionnaire (Attachment E)
When you receive the above documents, please print and sign, and return them with original signatures along with the following:
  • Copies of current Arkansas medical or nursing licenses, and DEA registrations if applicable, for each provider listed as an Individual Provider
  • Documentation of CME 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
 
Thirty (30) Days prior to your provider's medical/nursing license or DEA registration expiring, you will receive an email notification, informing you of expiration. Fax updated copies of each individual provider's Arkansas Medical or Nursing License, and DEA Registration (if applicable) prior to expiration to 501-661-2189, Attention BreastCare Provider Management.
 
If you have any questions or concerns, please call the numbers listed below.
 
Questions About: Contact Phone Number
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