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 19-64 years of age, uninsured, low-income, and in need of treatment for breast or cervical cancer, including treatment for pre-cancerous conditions. Prior to applying for the Oklahoma Cares Program, a patient's eligibility and her qualifying medical condition must be verified by a certified screener of the Take Charge! Program, which is the local program under the National Breast and Cervical Cancer Early Detection Program funded by the Centers for Disease Control and Prevention (CDC). A patient cannot submit an Oklahoma Cares application without the signature of a certified screener of the Take Charge! Program, or her application will be rejected without review. To register as a certified screener of the Take Charge! Program, a medical provider must currently be licensed as one of the following: Doctor of Medicine (MD), Doctor of Osteopathic Medicine (DO), Nurse Practitioner (NP), Certified Nurse Midwife (CNM), Clinical Nurse Specialist (CNS), or Physician Assistant (PA). A medical provider with valid credentials can register by either filling out the registration form on this page, or signing the Memorandum of Understanding at a notary. If you prefer to use the Memorandum of Understanding, please contact our office by phone or email.

The purpose of this Partnership Agreement (hereinafter referred to as “the Agreement") is to obtain acknowledgement and commitment from a licensed healthcare provider to perform the responsibilities stated within this Agreement as a certified screener of the Take Charge! Program and to help eligible patients apply for Medicaid benefits offered through the Oklahoma Cares Program.

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

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

• Provide education and training for the Take Charge! Program 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 procedures;

• Provide pre- and post-application consultation;

• Maintain current and accurate information for the program database;

• Make changes to database and update records whenever requested.

Take Charge! Program Certified Screeners

The certified screeners of the Take Charge! Program are responsible for identifying patients who are eligible for the Oklahoma Cares Program, and file a BCC-1 Form/Patient Application for each patient who meets the following eligibility criteria:

•    The patient is female;

•    The patient is between the ages of 19 and 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 got a breast or cervical cancer screening with abnormal findings that

require further diagnosis and/or treatment;

•    The patient currently has no creditable health insurance coverage; and

•    The patient has an income at or below 185% of the current Federal Poverty Level.

• This Agreement does not constitute, in any way, a commitment of funds

            between either party;

• The program is not to be held liable for reimbursement of any screening,

            diagnosis, or treatment services;

• Funds spent on any activities related to the commitment to the program will be

            voluntary and be in accordance with individual organization’s internal policies.

Any claims, disputes or litigation relating to the solicitation, execution, interpretation, performance, or enforcement of this Agreement shall be governed by the laws of the State of Oklahoma the venue for any action, claim, dispute or litigation relating in any way to this Agreement shall be Oklahoma County.

The parties intend that each party shall be responsible for its own intentional and negligent acts or omissions to act. The OSDH shall be responsible for the acts and omissions to act of its members while acting within the scope of this project. Each signing licensed healthcare provider agrees to hold harmless OSDH of any claims, demands and liabilities resulting from any act or omission on the part of the program and/or its members in the performance of this Agreement. It is the express intention of the parties that this Agreement shall NOT be construed as, or given the effect of, creating a joint venture, partnership or affiliation or association that would otherwise render the parties liable as partners, agents, employer-employee or otherwise create any joint and several liability.

This document constitutes the entire agreement for the responsibilities between the signing licensed healthcare provider and OSDH – Take Charge! Program. Any additions or deletions to this Agreement shall require the execution of a new Partnership Agreement, which will then supersede this Agreement.

The signing healthcare provider may not use the OSDH name or logos without the explicit written permission of OSDH.

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

The signing of this agreement implies that both parties will strive to satisfy the responsibilities herein.

Please read before proceeding:

• This information must be acknowledged, completed, and submitted by the

          licensed healthcare provider him-/herself;

• If multiple licensed healthcare providers within the same organization are registering at the same time, each provider must fill out and submit his/her own registration form separately.

I am a licensed healthcare provider in good standing. I have read and understand 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 Partnership Agreement is in effect, I will receive the electronic copy of the program eligibility checklist and BCC-1 Forms/Patient Applications in English (2014) and Spanish (2013) 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.