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)
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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
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Send your completed packet to the following address:
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Attn: BreastCare Provider Management
Arkansas Department of Health
4815 W Markham St, Slot 11
Little Rock, AR 72205-3867
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Additional Information
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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.
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If you have any questions or concerns, please call the numbers listed below.
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