Certified Screener Registration Form for Oklahoma County Health Departments

Effective January 2005, the Oklahoma State Department of Health (OSDH), the Oklahoma Health Care Authority (OHCA), the Oklahoma Department of Human Services (OKDHS), Cherokee Nation, and Kaw Nation collaborated to implement a Medicaid plan amendment. The amendment allowed the OHCA to provide comprehensive Medicaid benefits through the Oklahoma Cares Program to women who are uninsured, low-income, and in need of treatment for breast or cervical cancer, including treatment for pre-cancerous conditions. Prior to applying for the program, an eligible client must be screened and referred by a provider certified by the Centers for Disease Control and Prevention (CDC) funded Breast and Cervical Cancer Early Detection Program, locally known as the Take Charge! Program (hereinafter referred to as “the program”). If you are a Registered Nurse (RN), an Advanced Practice Registered Nurse (APRN), or a Licensed Practical Nurse (LPN) employed at a County Health Department of Oklahoma (excluding health departments in Oklahoma County and Tulsa County) and would like to become a certified screener to help patients apply for breast/cervical cancer treatment assistance, please fill out this registration form after completing the program trainings. Once your request has been approved by the District Nurse Manager, we will follow up with a confirmation email shortly.

Oklahoma State Department of Health (OSDH) -- Take Charge! Program

The OSDH – Take Charge! Program is committed to the following responsibilities for all certified providers and eligible clients:

• Provide education and training of the Take Charge! and the Oklahoma Cares

Program;

• Provide BCC-1 Application Forms and other supplementary documents;
• Provide program navigation, enrollment assistance, and referral services for

     breast and cervical cancer diagnostic and treatment; Provide pre- and post-

application consultation;

• Maintain current and accurate information for the program database and

update records when requested.

Certified Healthcare Providers

The certified providers of the Take Charge! Program are responsible for identifying patients who potentially meet the program requirements during practice, verify each program requirement with the patient, refer those who are eligible to the program, and file a BCC-1 Application if the patient wishes to do so. The program requirements are the following:

• The patient is female;
• The patient is between the ages of 19 to 65;
• The patient is a U.S. citizen or lawful permanent resident;
• The patient has declared her Social Security Number (SSN);
• The patient is a resident of the State of Oklahoma;
• The patient has breast or cervical cancer screening with abnormal clinical

findings that require further diagnosis and/or treatment;

• The patient has no creditable health insurance coverage; and
• The patient has an income at or below 185% of the current Federal Poverty

Level.

Toll-Free Program Helpline: 866-550-5585 Program Coordinator: Victoria Yan Phone: 405-426-8304 Email: OKCares@health.ok.gov

I am a RN/APRN in good standing and employed at the local county health department that is not within Oklahoma County or Tulsa County in the State of Oklahoma. I have completed the Breast and Cervical Cancer Treatment Program trainings and would like to become a certified screener to sign the BCC-1 Forms. I have read and understood the terms and conditions of this agreement. By entering my information in the sections below, I agree to abide by the terms and conditions of the agreement.

I understand that once the registration is completed, I will receive the electronic copy of the program eligibility checklist and BCC-1 Forms/Patient Applications in English and Spanish via the email address provided above. I hereby certify all information provided is true and correct to the best of my knowledge. By clicking “SUBMIT” below, I understand it constitutes an electronic signature of this form, and my electronic signature shall have the same force and effect as my written signature.