Get the free BC-100, BCCTP Referral Form - Arizona Department of Health ... - azdhs

CCTP Eligibility Screening Worksheet & Documentation Requirements TO: FROM (Provider Name and Address): Arizona Department of Health Services (ADDS) 150 N. 18th Ave., Suite 300 Phoenix, AZ 85007 Phone:

How to fill out bc-100 bcctp referral form

How to fill out the BC-100 BCCTP referral form:

1. Begin by entering the patient's information in the designated fields, such as their name, date of birth, and contact details.
2. Next, provide the referring physician's information, including their name, contact information, and medical license number.
3. Make sure to accurately enter the date of the referral and the reason for the referral. Include any relevant medical history or diagnostic information that supports the need for the BCCTP program.
4. Indicate whether the patient is eligible for Medicare or Medicaid and provide their corresponding identification numbers, if applicable.
5. Specify the desired start date for the patient's BCCTP coverage, keeping in mind any waiting periods that may apply.
6. If the referral is for a specific service or treatment, clearly state the details, including the recommended procedure or intervention, along with any supporting documentation.
7. Sign and date the referral form, ensuring that the referring physician's signature is legible and matches the name entered on the form.
8. Retain a copy of the completed referral form for your records and provide a copy to the patient to keep for their own records.

Who needs the BC-100 BCCTP referral form:

1. Patients who require specialized healthcare services, treatments, or procedures that are covered by the BCCTP program may need to have their referring physician complete the BC-100 referral form.
2. The BCCTP program is designed for patients who are eligible for Medicare or Medicaid and have specific healthcare needs that fall within the program's coverage guidelines.
3. It is important to consult with the BCCTP program guidelines or contact the appropriate administrative office to determine whether a referral form is required for a specific patient's situation.

For pdfFiller’s FAQs

How can I send bc-100 bcctp referral form for eSignature?

When you're ready to share your bc-100 bcctp referral form, you can swiftly email it to others and receive the eSigned document back. You may send your PDF through email, fax, text message, or USPS mail, or you can notarize it online. All of this may be done without ever leaving your account.

How can I get bc-100 bcctp referral form?

The premium subscription for pdfFiller provides you with access to an extensive library of fillable forms (over 25M fillable templates) that you can download, fill out, print, and sign. You won’t have any trouble finding state-specific bc-100 bcctp referral form and other forms in the library. Find the template you need and customize it using advanced editing functionalities.

Can I create an eSignature for the bc-100 bcctp referral form in Gmail?

When you use pdfFiller's add-on for Gmail, you can add or type a signature. You can also draw a signature. pdfFiller lets you eSign your bc-100 bcctp referral form and other documents right from your email. In order to keep signed documents and your own signatures, you need to sign up for an account.

What is bc-100 bcctp referral form?

The bc-100 bcctp referral form is a form used to refer patients to the Breast and Cervical Cancer Treatment Program.

Who is required to file bc-100 bcctp referral form?

Healthcare providers and facilities are required to file the bc-100 bcctp referral form when referring patients to the program.

How to fill out bc-100 bcctp referral form?

The bc-100 bcctp referral form should be filled out with the patient's information, the provider's information, and details about the referral.

What is the purpose of bc-100 bcctp referral form?

The purpose of the bc-100 bcctp referral form is to facilitate referrals to the Breast and Cervical Cancer Treatment Program.

What information must be reported on bc-100 bcctp referral form?

The bc-100 bcctp referral form must include patient demographics, diagnosis information, treatment plan, and provider information.