Healthy Communities

BreastCare Provider Forms and Manuals

Billing Forms and Information

BreastCare Billing System User Access Form

Billing Manual- Updated December 2016

Procedure Codes to Provider Types/Specialties/Diagnosis Codes – Updated December 2016

BreastCare Claim Form

2017 Reimbursement Rates: Breast (Effective January 1, 2017)

2017 Reimbursement Rates: Cervical (Effective January 1, 2017)


Patient Care Forms

Arkansas Tobacco Quitline Fax Referral Form – English | Spanish

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


Provider Management Forms

Authorization for Automatic Deposit Form

Provider Information Change Form

Provider Name and Specialty Form

Public Health Accrediation Board
Arkansas Department of Health
© 2017 Arkansas Department of Health. All Rights Reserved. |
4815 W. Markham, Little Rock, AR 72205-3867 | 1-800-462-0599