Providers

BCC Program New Provider Application Documents

• New Provider Application
• Provider Contact Form
• Provider Credential List
• Substitute W-9
• Campaign Contribution Disclosure Form

BCC Program Current Provider Forms and Documents

Eligibility, Screening, and Referral Forms:

• FY25 Eligibility and Consent Form (English)
• FY25 Eligibility and Consent Form (Spanish)
• FY25 Screening and Referral Form (Print Version)
• FY25 Screening and Referral Form (Fillable)

Clinical Protocol:

• BCC Clinical Protocol Effective 8/20/2021

Patient Navigation Resources:

• FY25 Clinic Based Patient Navigation Form (Print Version)
• FY25 Clinic Based Patient Navigation Form (PDF Fillable Version)
• George Washington Cancer Center Oncology Patient Navigator Training: The Fundamentals

Case Management:

For Case Management needs please contact the Interim BCC Program Case Manager:

Blanca Vargas
505-250-6493
505-533-6078

Billing and Administration:

• DFA Agency Certification Form
• FY25 CPT Codes
• Substitute W-9
• Campaign Contribution Disclosure Form

Clinical Prior Authorization and Reimbursement Policies:

• Procedures Requiring Prior Authorization
• MRI Reimbursement Policy
• Diagnostic Excisional Procedures
• Cervical Cancer Post Treatment Surveillance
• Endometrial Biopsy

Screening Recommendations, Diagnostic Guidelines and Breast Cancer Risk Evaluation Tool:

• U.S. Preventive Services Task Force Breast Cancer: Screening Recommendation
• U.S. Preventive Services Task Force Cervical Cancer: Screening Recommendation
• ASCCP Risk-Based Management Consensus Guidelines for Abnormal Cervical Cancer Screening Tests and Cancer Precursors
• NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Breast Cancer Screening and Diagnosis

BCC Program Contacts:

• Breast and Cervical Cancer Early Detection Program Staff Directory