Take Charge needs information for all authorized licensed medical providers that will provide services for Take Charge clients in Fiscal Year 2026. Please fill out one form per provider and attach current copies of any of the below items that are applicable to the provider.

• Copy of State of Oklahoma license to practice for all healthcare providers delivering breast and cervical cancer screening for Take Charge! clients
• Copy of any relevant board certification(s)
• Copy of medical malpractice insurance
• Copy of any relevant accreditation(s)
• Copy of CLIA certification (if in-house lab present and utilized)
• Copy of Medicare and Medicaid certified facility documentation
• Copy of subcontract(s) and any copies of relevant licenses, insurance certifications, and accreditation(s) for the subcontracts