For more information, call (478)254-5204. Address: CGCC-BHP, PO Box 25, Macon, GA 31201 2011 BREAST HEALTH PROGRAM INSTRUCTIONS FOR MEDICAL PROVIDERS ● This grant-funded program pays for screening mammography and diagnostic services. ● A physician’s office, clinic, or diagnostic center may refer patients into the program with a completed Certificate Request Form & medical order. A copy of the Certificate Request Form is available by request or online at http://www.chwg.org/index.php/about-us/leadership-a-staff/coalitions/cancer- coalition.html ● The referring provider gives the patient an Income Eligibility Packet (also online) for submission to CGCC which prescreens for eligibility based on the following criteria: - Patient is 40-64 years of age (or other with a compelling reason to receive mammography screening such as existing breast problems, a lump, previous abnormal screening, etc.) - Patient is uninsured or under-insured - Patient is low-income (income 200% of Federal Poverty Level or less) ● The referring provider schedules the mammogram appointment with a participating mammogram/diagnostic center and faxes the Certificate Request Form and medical order to CGCC to request approval with an assigned unique certificate number: CGCC Breast Health Program Coordinator: Jen Sandefur Fax: 478-254-5239 ● Upon receipt of the certificate number, the referring provider then transmits a copy of the Certificate Request Form to the mammogram/diagnostic facility for referencing on their invoice when billing. Medical Providers should refer patients to partnering facilities listed below. CGCC can only pay for services that take place at these partnering facilities: MCCG (Central Georgia Breast Care Center) – Jane Perazzola 478.633.6328 Houston Healthcare (Perry Hospital or Pavillion Diagnostic) – Nichole Hardage 478.923.1830 x350 Upson Regional Medical Center – Wanda Wilson 706.647.8111 x1473 Oconee Regional Medical Center – Tammy Everett 478.457.2117 HCA Coliseum Hospital – Kimberly Lewis 478.464.1370 Taylor Regional Hospital – Kema Norlund 478.783.0288 Putnam General Hospital – Erica Sills 706.923.2059 ● Each certificate number is valid only for the service specified on the corresponding certificate form. Results of mammograms are reported to CGCC (normal/abnormal or indeterminate). If results are abnormal, provider’s office is to contact program coordinator at CGCC for additional certifications until a diagnosis of cancer or not is made.

Breast Health Program

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Description of the Central Georgia Cancer Coalition and the Ta-Ta Sisterhood

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For more information, call (478)254-5204. Address: CGCC-BHP, PO Box 25, Macon, GA 31201

2011 BREAST HEALTH PROGRAM INSTRUCTIONS FOR MEDICAL PROVIDERS

● This grant-funded program pays for screening mammography and diagnostic services. ● A physician’s office, clinic, or diagnostic center may refer patients into the program with a completed

Certificate Request Form & medical order. A copy of the Certificate Request Form is available by request or online at http://www.chwg.org/index.php/about-us/leadership-a-staff/coalitions/cancer-coalition.html

● The referring provider gives the patient an Income Eligibility Packet (also online) for submission to CGCC which prescreens for eligibility based on the following criteria:

- Patient is 40-64 years of age (or other with a compelling reason to receive mammography screening such as existing breast problems, a lump, previous abnormal screening, etc.)

- Patient is uninsured or under-insured - Patient is low-income (income 200% of Federal Poverty Level or less)

● The referring provider schedules the mammogram appointment with a participating

mammogram/diagnostic center and faxes the Certificate Request Form and medical order to CGCC to request approval with an assigned unique certificate number:

CGCC Breast Health Program Coordinator: Jen Sandefur

Fax: 478-254-5239 ● Upon receipt of the certificate number, the referring provider then transmits a copy of the Certificate

Request Form to the mammogram/diagnostic facility for referencing on their invoice when billing.

Medical Providers should refer patients to partnering facilities listed below. CGCC can only pay for services that take place at these partnering facilities:

MCCG (Central Georgia Breast Care Center) – Jane Perazzola 478.633.6328 Houston Healthcare (Perry Hospital or Pavillion Diagnostic) – Nichole Hardage 478.923.1830 x350

Upson Regional Medical Center – Wanda Wilson 706.647.8111 x1473 Oconee Regional Medical Center – Tammy Everett 478.457.2117 HCA Coliseum Hospital – Kimberly Lewis 478.464.1370 Taylor Regional Hospital – Kema Norlund 478.783.0288 Putnam General Hospital – Erica Sills 706.923.2059

● Each certificate number is valid only for the service specified on the corresponding certificate form. Results of mammograms are reported to CGCC (normal/abnormal or indeterminate). If results are abnormal, provider’s office is to contact program coordinator at CGCC for additional certifications until a diagnosis of cancer or not is made.