Breast and Cervical Cancer - Health Care Facility Program Enrollment

Care for Yourself - Breast and Cervical Cancer Program 

Thank you for you interest in providing health care services for participants in the Iowa Department of Public Health's (IDPH) Care for Yourself - Breast and Cervical Cancer Program.

The Care for Yourself Healthcare Provider Guide has important information that can be helpful to review prior to requesting enrollment into the program.

In order for IDPH to authorize payment of claims for enrolled Care for Yourself participants, the following agreements and corresponding documents must be accurately completed and fully executed with signatures from both parties. Please submit one Cooperative Agreement for the Corporation/Lead Facility and one Service Facility Application for each clinic or location where services will be provided. Please include an up to date W-9 form and, if applicable, a copy of the facility's Clinical Laboratory Improvement Amendments (CLIA) Certificate. 

Completed documents can be emailed or faxed to Gena Hodges at Gena.Hodges@idph.iowa.gov or 515-242-6384.

For further questions or to check the status of your facility's enrollment, please contact Gena Hodges at Gena.Hodges@idph.iowa.gov or 515-371-6306.

• BCC Cooperative Agreement 
• BCC Application for Facilities and Healthcare Providers  
• W-9 Form