Find all of the current program-related forms for the WA State BCCHP program below. All of the currently available languages are listed.

These forms are only for use by providers/clinics who are contracted with a Prime Contractor in their region to provide BCCHP services. For providers looking to participate in BCCHP or patients who are looking to enroll in the program, please reach out to the prime contractor for your region. If you have any questions or concerns about these forms, please contact zoey.hogan@doh.wa.gov.

BCCHP Enrollment Form DOH342-054
  • English .doc (July 2020)
  • Spanish .doc (July 2020)
  • Arabic .doc (July 2020)
  • Chinese (Traditional) .doc (July 2020)
  • Farsi .doc (July 2020)
  • Hindi .doc (July 2020)
  • Khmer .doc (July 2020)
  • Korean .doc (July 2020)
  • Marshallese .doc (July 2020)
  • Nepali .doc (July 2020)
  • Punjabi .doc (July 2020)
  • Russian .doc (July 2020)
  • Somali .doc (July 2020)
  • Tagalog .doc (July 2020)
  • Vietnamese .doc (July 2020)
BCCHP Consent Form DOH342-015
  • English .doc (July 2020)
  • Spanish .doc (Dec 2021)
  • Arabic .doc (July 2020)
  • Chinese (Traditional) .doc (July 2020)
  • Farsi .doc (July 2020)
  • Hindi .doc (July 2020)
  • Khmer .doc (July 2020)
  • Korean .doc (July 2020)
  • Marshallese .doc (July 2020)
  • Nepali .doc (July 2020)
  • Punjabi .doc (July 2020)
  • Russian .doc (July 2020)
  • Somali .doc (July 2020)
  • Tagalog .doc (July 2020)
  • Vietnamese .doc (July 2020)
Breast and Cervical History Exam Screening DOH342-057
  • English .doc (Sept 2021)
Breast Diagnostic Form DOH345-211
  • English .doc (Sept 2021)
Cervical Diagnostic Form DOH345-213
  • English .doc (Sept 2021)
BCCHP Imaging Form DOH345-212
  • English .doc (Sept 2021)
Navigation-Only Contact Form DOH349-046
  • English .doc (Sept 2021)
Navigation-Only Consent Form DOH349-049
  • English .doc (Oct 2021)
  • Spanish .doc (Oct 2021)
  • Arabic .doc (Oct 2021)
  • Chinese (Traditional) .doc (Oct 2021)
  • Farsi .doc (Oct 2021)
  • Hindi .doc (Oct 2021)
  • Khmer .doc (Oct 2021)
  • Korean .doc (Oct 2021)
  • Marshallese .doc (Oct 2021)
  • Nepali .doc (Oct 2021)
  • Punjabi .doc (Oct 2021)
  • Russian .doc (Oct 2021)
  • Somali .doc (Oct 2021)
  • Tagalog .doc (Oct 2021)
  • Vietnamese .doc (Oct 2021)
Prior Authorization Form DOH342-117
  • English .doc (Jan 2022)