Breast & Cervical Cancer—Healthcare Entity and Facility Program Enrollment

For Iowa HHS to authorize payment of Iowa Care for Yourself participant claims, both the service entity and each facility under that entity providing authorized services must have an active Service Entity Agreement and be designated as an approved facility. 

Enrollment Process

Service Entity Enrollment Process

Service Entities must secure an active and approved Service Entity Agreement before any facilities under their Tax ID can enroll. The Service Entity Agreement should be completed by an administrative or billing representative at the parent organization, ensuring we have the correct contact for future billing notices and reimbursement updates. To enroll: 

• Complete one Service Entity Agreement per Tax ID.
• Fill out the form digitally and obtain signatures from both the Service Entity and Iowa HHS.
• Submit additional agreements if you operate under multiple Tax IDs.
• Include a copy of your most current W-9 form. 

Send completed documents to CareforYourself@hhs.iowa.gov.  

The date Iowa HHS signs your Service Entity Agreement marks the start of your six-year enrollment period. Iowa HHS will return the fully executed agreement for your records. 

Facility Enrollment Process

Facilities may apply only after their parent Service Entity has an active, signed agreement. The Facility Application should be filled out by on-site personnel at the clinic or facility that actually conducts the screening and diagnostic services, so we can directly reach the staff responsible for day-to-day operations and provider communications. To enroll each location: 

• Facility Application: Online Form
• Submit one Facility Application per facility address (or clinic name). If there are multiple facilities, multiple applications are required.
• Prefer one clinic/facility NPI rather than individual provider NPIs.
• Provide a copy of each facility’s CLIA certificate to CareforYourself@hhs.iowa.gov.
• Required for in-office testing (Pap cytology, HPV, breast biopsy, waived tests).
• Not required for facilities offering only mammograms, breast ultrasounds or breast MRIs.
• Send updated certificates whenever they expire or change. 

Once your online application and CLIA certificate are received, Iowa HHS will process your request and email you when the facility is approved. Facility approval remains in effect until the expiration date of your Service Entity Agreement. 

If you have questions or need assistance, email CareforYourself@hhs.iowa.gov. You may represent both an entity and a facility or the entity and facility may be the same. You can fill out the information for both the entity and the facility, but an approved Service Entity Agreement is necessary before filling out information for the facility.