Local Coordinating Unit | Department of Health

Medium

Medium

April 2021-March 2022 Income Guidelines

BCBS Secure Mail Transmittal

LCU Contact information

Medium

Women's Way Forms

Authorization for Disclosure of PHI

Authorization for Disclosure of PHI - Spanish

Demographic Form

Intake and Visit Form

Breast Diagnostic Form

Cervical Diagnostic Form

Spanish Latin American Demographic Form

Spanish Mexican Demographic Form

Women's Way Referral Form

Process to Complete Secure Mail Transmittal

BCBS Secure Transmittal Form

Informed Refusal Form

NDQuits Fax Referral Form

Medicaid Forms

Medicaid-Women's Way Application

Estate Recovery

Verification of Diagnosis

Completion of Treatment Form

Treatment Options for Women's Way Clients

ND Medicaid BCCEDP Checklist for LCUs

ND Medicaid BCCEDP Fact Sheet for Women's Way Clients

Process to Complete Authorization to Disclose Information for ND DHS

Authorization to Disclose Information for ND DHS

Medium

Women's Way Program Manual

Breast Cancer Screening Policy

Cervical Cancer Screening Policy

Women's Way Enrollment Policy

LCU Process for Reviewing Paid Claims

Guidelines for Request for Resource Funds

Standards for Women's Way Logo

Other Documents

COVID Vaccine & Mammography

Medium

Last reviewed 4/13/2021