Flyers
- BCN Free Screening Flyer (pdf)
- Español (formato PDF)
- BCN Income Guidelines (pdf)
- Español (formato PDF)
Fact Sheets
- Breast Cancer in SC Facts (pdf)
- South Carolina Cancer Alliance (SCCA) Cervical Cancer Information (pdf)
- South Carolina Cancer Alliance (SCCA) Cancer Survivorship (pdf)
- Español (formato PDF)
Contracted Provider Forms
Patient Enrollment Forms
- Document Verification Checklist (pdf)
- Español (formato PDF)
- No Proof Form (pdf)
- Español (formato PDF)
- Prior Authorization Code Request Form (pdf)
Office Visit Reimbursements
- Breast/Cervical Cost Explanation Form (pdf)
- Español (formato PDF)
- Notice of Privacy Practices (HIPAA) Brochure (pdf)
- Screening/Billing Form (pdf)
Breast Diagnostic Reimbursements
- Breast Services Cost Explanation Form (pdf)
- Español (formato PDF)
- Notice of Privacy Practices (HIPAA) Brochure (pdf)
- Breast Follow-up Billing Form (pdf) *Providers must submit all visit reports/results.
Cervical Diagnostic Reimbursements
- Cervical Services Cost Explanation Form (pdf)
- Español (formato PDF)
- Notice of Privacy Practices (HIPAA) Brochure (pdf)
- Cervical Follow-up Billing Form (pdf) *Providers must submit all visit reports/results and prior Pap results.
Imaging/Radiology Services and Lab/Pathology Reimbursements
Providers must submit an appropriate CMS 1500/UB04 form with all visits reports/results.
- CMS 1500 Form (pdf)
- UB04 Form (pdf)
Patient Navigation Assistance
Providers may fill out and fax to BCN Nurses for navigation assistance.