Forms

Form number	Title
After Hours	After Hours Participation Form
CH-1	Week Old Visit
CH-2	1 Month Visit
CH-3	2 Month Visit
CH-4	4 Month Visit
CH-5	6 Month Visit
CH-6	9 Month Visit
CH-7	12 Month Visit
CH-8	15 Month Visit
CH-9	18 Month Visit
CH-10	24 Month Visit
CH-11	3 Year Old Visit
CH-12	4 Year Old Visit
CH-13	5 Year Old Visit
CH-14	6 to 10 Year Old Visit
CH-15	11 to 20 Year Old Visit
CH-16 English - Spanish	Psychosocial Assessment
CH-18	"5As" Tobacco Cessation Counseling Form Tobacco Cessation Benefits Explained
Dental - Caries Risk Assessment Form	Caries Risk Assessment Form
Dental - ICD 10 Information	ICD-10 Information (Dental)
DEN-2	Orthodontic Treatment
DEN-3	Change of Dental Provider Request
DEN-6	Handicapping Labio-Lingual Deviation Index of Malocclusion
EHR-01	EHR Flexibility Rule Form
EHR-02	EHR-Hospital Payment Documentation Form
FIN-01	Disproportionate Share Hospital Worksheet
HCA-3 English - Spanish	Elective Sterilization Consent
HCA-3A English - Spanish	Hysterectomy Acknowledgement
HCA-3B	Certificate for Abortion
HCA-12A	Prior Authorization with Required Documentation for Web PA Attached
HCA-13	Coversheet for paper attachment to electronic claim
HCA-13A	Coversheet for paper attachment to prior authorization
HCA-13D	Dental Prior Authorization
HCA-14	UB92 and Inpatient/Outpatient Crossover Adjustment Request
HCA-15	Paid Claim Adjustment Request for Crossover Part B, Dental, CMS 1500
HCA-17	Claim Appeal and Review
HCA-18	Request for Duplicate Provider Remittance Statement
HCA-20 English - Spanish	Authorization to Release Medicaid Records
HCA-24	Care Coordination Referral Form
HCA-25	Medical Necessity for Air Transport
HCA-27	Physician’s Certification Statement
HCA-28 \| Instructions	Medicare-Medicaid Crossover Invoice (Inpatient claims and all claims prior to DOS 6/1/2016)
HCA-28B \| Instructions	Medicare-Medicaid Crossover Invoice (Outpatient and HCFA 1500 claims after DOS 5/31/2016)
HCA-29	Certificate of Medical Necessity - External Infusion Pump
HCA-30	Certificate of Medical Necessity - Hospital Beds
HCA-32	Certificate of Medical Necessity - Oxygen
HCA-33	Certificate of Medical Necessity - Pneumatic Compression Devices
HCA-34	Certificate of Medical Necessity - Osteogenesis Stimulators
HCA-37	Certificate of Medical Necessity - Support Surfaces
HCA-38	Certificate of Medical Necessity - Enteral and Parenteral Nutrition
HCA-40	Nursing Home Ambulance Transportation Form
HCA-41 (LM)	Lodging and/or Meals Authorization Form (voucher)
HCA-42	SoonerCare Patient Dismissal request Form
HCA-43	Physician Statement for Therapeutic Shoes
HCA-47	Provider Self Disclosure Form
HCA-48	Fraud Referral
HCA 49	DMERP Provider Prior Authorization Attestation
HCA-50	Manual Pricing Checklist
HCA-52	Physician Order for Incontinence Supplies
HCA-60	Prior Authorization Amendment Form
HCA-61	Therapy Prior Authorization Request Form
HCA-64	Meals and Lodging Request Form
HCA-65	Out of State Prior Authorization Request
HCA-NB1	Issued 6-7-07
Insure Oklahoma	Insure Oklahoma Children Form
LD-1 English \| Spanish	Member Complaint/Grievance Form
LD-2	Provider/Physician Grievance Form
LD-3	Provider/Physician Appeal Form
LTC-7	LTC-7 Level of Care Determination
LTC-10	Nurse Aid Training Reimbursement Worksheet
LTC-11	PACE Waiver Request Form
LTC-12	PACE Request for Deeming of Continued Eligibility
LTC-300	ICF-MR Level of Care Assessment Form with Instructions
LTC-300R	Nursing Facility Level of Care Assessment
LTC-300R	Nursing Facility Level of Care Assessment Guidelines for Completion
OSF-20A	Request for Replacement of Warrant
OSF-20B	Request for Replacement Affidavit
Pharmacy Forms
QOCR Instructions	QOCR Instructions
QOCR	Quality of Care
SC-10	SoonerCare/Insure Oklahoma Referral Form
SC-12	Issued 02-01-08 Provider Training Request Form
SC-13	SoonerCare Choice Provider Change Request
SC-14	SoonerCare Administrative Referral Request
SC-15 English \| Spanish	Parental Consent Form
SC-16 English \| Spanish	Change of Provider Request
TPL-1	Third Party Liability Information Sheet

providers

Forms