| Form number |
Title |
| 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 |
2 Year Old 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-17 |
High Risk Ob Form |
| CH-18 |
5As Tobacco Cessation Counseling Form |
| DEN-1 |
Confirmation of Pregnancy Form |
| DEN-2 |
Orthodontic Treatment |
| DEN-3 |
Change of Dental Provider Request |
| EHR - 02 |
EHR-Hospital Payment Documentation Form |
| FIN-01 |
Disproportionate Share Hospital Worksheet |
| FPWS-01 |
Application for Family Planning Services |
| 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-14 |
UB92 and Inpatient/Outpatient Crossover Adjustment Request |
| HCA-15 |
Paid Claim Adjustment Request for Crossover Part B, Dental, CMS 1500 |
| HCA-17 |
Claim Inquiry Response |
| HCA-18 |
Request for Duplicate Provider Remittance Statement (beyond 60 days) |
| HCA-20 English - Spanish |
Authorization to Release Medicaid Records |
| HCA-24 |
Care Management Referral |
| HCA-25 |
Medical Necessity for Air Transport |
| HCA-27 |
Physician’s Certification Statement |
| HCA-28 |
Medicare-Medicaid Crossover Invoice |
| 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-35 |
Certificate of Medical Necessity - Seat Lift Mechanisms |
| HCA-36 |
Certificate of Medical Necessity - Respiratory Assist Device - CPAP and BIPAP |
| HCA-37 |
Certificate of Medical Necessity - Support Surfaces |
| HCA-38 |
Certificate of Medical Necessity - Enteral and Parenteral Nutrition |
| HCA-39 |
Certificate of Medical Necessity - Transcutaneous Electrical Nerve Simulator (TENS) |
| 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-44 |
OHCA Telemedicine Consent Form |
| HCA-47 |
Provider Self Disclosure Form |
| HCA-48 |
Fraud Referral |
| HCA 49 |
DMERP Provider Prior Authorization Attestation |
| HCA-NB1 |
Issued 6-7-07 |
| HLD-1 |
Orthodontia |
| Insure Oklahoma |
Insure Oklahoma Children Form |
| LCP |
Living Choice Project Forms |
| LD-1 English | Spanish |
Member Complaint/Grievance Form |
| LD-2 |
Provider/Physician Grievance Form |
| LD-5 |
Form Memo Regarding Appellants in SURS Cases |
| LTC-7 |
LTC-7 Level of Care Determination |
| LTC-10 |
Nurse Aid Training Reimbursement Worksheet |
| 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 |
| PHARM-01 |
Pharmacy Claim |
| PHARM-02 |
Compound Prescription Drug Claim |
| PHARM-03 |
Pharmacy Paid Claim Adjustment Request |
| PHARM-04 |
Universal Petition for Medication Authorization |
| PHARM-06 |
Petition for Tuberculosis Related Therapy Authorization |
| PHARM-07 |
Petition for Synagis Authorization |
| PHARM-07S |
Supplemental Synagis Dosing Form |
| PHARM-09 |
Medication Therapy Management Services Referral Form |
| PHARM-11 |
Statement of Medical Necessity for Brand-Name Drug Override |
| PHARM-12 |
Statement of Medical Necessity for Early Fill Override |
| PHARM-13 |
Statement of Medical Necessity for Quantity Limit Override |
| PHARM-14 |
Statement of Medical Necessity for Xolair |
| PHARM-16 |
Pharmacy Lock-In Referral |
| PHARM-17 |
ESA Petition |
| PHARM-18 |
Outpatient Medication Petition |
| PHARM-20 |
Growth Hormone PA |
| PHARM-23 |
Prior Authorization Form: Makena® (17-hydroxyprogesterone caproate) |
| PHARM-24 |
Botox |
| QOCR Instructions |
QOCR Instructions |
| QOCR |
Quality of Care |
| SC-10 |
SoonerCare Choice Referral Form with Guidelines and Instructions |
| SC-12 |
Issued 02-01-08 Provider Training Request Form |
| SC-13 |
SoonerCare Choice Provider Change Request (Formally SC-11- PDF still titled SC-11) |
| SC-14 |
SoonerCare Referral Request |
| SC-15 |
Parental Consent Form |
| SC-16 |
Change of Provider Request |
| TPL-1 |
Third Party Liability Information Sheet |