Eligibility Requirements    

Gaining Access to WISEWOMAN Data and Billing System: Use this form to request a password and user name for the data and billing system.

Required Forms and Required Resources

Patients' Rights and Responsibilities Brochure (English)

Spanish version  |  Chinese version    |   Korean version   |   Russian version   |  Vietnamese Version

 

Enrollment/Re-enrollment Form - Must be filled out for any women enrolled in BCCP/WISEWOMAN. Basic patient information and eligibility information is required as well as a signed client consent.  
Spanish version   |  Chinese version   |  Russian version 

Assessment Form (Revised July 1, 2011)  - this form parallels the electronic data fields for the assessment cycle for WISEWOMAN clients. It is used to record health history, family history and other information to evaluate a WISEWOMAN client's potential risk factors and lifestyle choices. Spanish version

Screening Form (Revised July 1, 2011) - the screening form parallels the electronic data base fields for the screening cycle for WISEWOMAN clients. It is used to record information related to screening tests covered by the Oregon WISEWOMAN program.   

My Health Information is provided to clients to record the results of their WISEWOMAN screening tests. Illustrations provide clients with an easy way to interpret if their personal test results are considered in the normal, abnormal or alert range. Tips on leading a healthy lifestyle are also included.
Spanish version   |  Chinese version   |  Russian version 

Community Resources is provided to clients with information and resources geared towards smoking cessation, healthy eating. and physical activity.
Spanish version   |  Chinese version   |  Russian version 

New Leaf Delivery Form (Revised July 1, 2011) - The New Leaf delivery form is used to record information related to the Lifestyle Intervention (LSI) sessions delivered by the WISEWOMAN provider.

 

CPT and ICD-9 codes for WISEWOMAN: This document lists the allowable procedures and the corresponding Current Procedural Terminology (CPT) codes for use in the Oregon WISEWOMAN program. It is updated annually. It does not include reimbursement information.