Breast & Cervical Cancer - Health Care Facility Program Enrollment

For Iowa HHS to authorize payment of BCC participant claims, the corporation and facilities under that corporation providing authorized services must have an active enrollment.

To enroll as a service provider to provide breast and cervical cancer related screenings and authorized services to program participants, return the following completed bulleted items.

  • One Cooperative Agreement per tax ID (needs to be signed and dated on page 5)
  • One Service Facility Application for each facility you are enrolling to provide breast and cervical cancer screening services. (sign and date at the bottom of the page)
  • A copy of each facility's Clinical Laboratory Improvement Amendments (CLIA) Certificate, if applicable.
  • A copy of the most current W-9 form (2018) signed off within the past 12-months.

Technical assistance to complete the enrollment process is available by sending an email request to gena.hodges@idph.iowa.gov

Scan or fax completed enrollment documents to Gena, at gena.hodges@idph.iowa.gov, or fax to Gena at: 515-242-6384.

Once the department receives your application, it takes 45 days to complete the enrollment process and return your corporations official documents.  The date the department signs off on your corporations Cooperative Agreement is the date your enrollment becomes active and remains active for six years from that date.

Exceptions to the six-year active period could happen under any of the following conditions:

  • The competitive grants scope of work changes and new enrollments are required of the department;
  • The corporation address or tax ID number changes;
  • The corporations facilities are not following through with the scope of work,
  • The corporation, it’s facilities or on-duty staff have a legal violation takes place within the scope of work of the BCC Program; or
  • The corporation goes through the steps in the State of Iowa General Conditions to end the contract.

Call Gena if you have questions about the enrollment process at 515-314-8318.

Enrollment or re-enrollment forms to complete:
BCC Cooperative Agreement
BCC Service Facility Application
W-9 Form