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, 2021 thru June 30, 2023. All PHSAs after June 30, 2021 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)
  • Third-Party Biller Authorization Form (Attachment F), if applicable
When you receive the above documents, please sign and return them 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
There are now two ways you can return the signed agreement and documents.
1.If signed electronically or paper copy signed and scanned, you may upload the agreement and all documents to our secure ADH Internet Applications website. To do so, follow the steps below.
  a.Login to ADH Internet Applications (https://health.arkansas.gov/ADHInternetApps/). You will be sent an email to set up your account.
b.Click on BreastCare Prov. File Copy
c.Select the Agreement-level Provider
d.Browse for the file to upload and select it
e.Click Upload Chosen File
Note: If you submitted multiple agreements, you will need to upload them separately.
2.If paper copy signed with original signatures, you can also mail to:
Arkansas Department of Health
Attn: BreastCare Provider Management
4815 W Markham St, Slot 11
Little Rock, AR  72205-3867
 
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, or 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 — Chastity Armstrong 1-800-462-0599, ext. 661-2947