| 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 |
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
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-4 |
Orthodontic Expectations Agreement |
| 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 Inquiry Response |
| HCA-18 |
Request for Duplicate Provider Remittance Statement |
| 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 (Inpatient claims and all claims prior to DOS 6/1/2016) |
| HCA-28B |
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-44 |
OHCA Telemedicine Consent Form |
| 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-NB1 |
Issued 6-7-07 |
| 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-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 |
|
| PHARM-01 |
Drug Claim Form |
| 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 (available October 2017) |
| 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-14A |
Statement of Medical Necessity for Xolair for Asthma |
| PHARM-14B |
Statement of Medical Necessity for Xolair for Chronic Idiopathic Urticaria |
| PHARM-16 |
Pharmacy Lock-In Referral |
| PHARM-17 |
ESA Petition |
| PHARM-18 |
Outpatient Medication Petition |
| PHARM-20 |
Growth Hormone PA |
| Pharm-23 |
Makena, Crinone, and Endometrin |
| PHARM-24 |
Botulinum Toxins |
| PHARM-25 |
State of Medical Necessity for Ingredient Duplication Override |
| PHARM-26 |
Sovaldi Initiation |
| PHARM-27 |
Olysio Initiation |
| PHARM-28 |
Hepatitis C Therapy Intent to Treat Contract |
| PHARM-29 |
Hepatitis C Therapy Pharmacy Agreement |
| PHARM-30 |
Hepatitis C Therapy Continuation |
| PHARM-33 |
Harvoni Initiation |
| PHARM-34 |
Viekira Pak Initiation |
| PHARM-35 |
Diabetic Supplies PA |
| PHARM-36 |
Technivie Initiation |
| PHARM-37 |
Daklinza Initiation |
| PHARM-38 |
PCSK9 Inhibitor PA |
| PHARM-39 |
Kadcyla PA |
| PHARM-40 |
Halaven PA |
| PHARM-41 |
Afinitor PA |
| PHARM-42 |
Ixempra PA |
| PHARM-43 |
Tykerb PA |
| PHARM-44 |
Ibrance PA |
| PHARM-45 |
Perjeta PA |
| PHARM-46 |
Zepatier PA |
| PHARM-47 |
Nucala PA |
| PHARM-49 |
Hemophilia Dispensing |
| PHARM-50 |
Hemophilia PA |
| PHARM-51 |
Hemophilia Consent |
| PHARM-52 |
Epclusa Initiation |
| PHARM-53 |
Hemophilia Standards of Care |
| PHARM-54 |
Jevtana PA |
| PHARM-55 |
Xtandi PA |
| PHARM-56 |
Zytiga PA |
| PHARM-57 |
Provenge PA |
| PHARM-58 |
Xofigo PA |
| PHARM-59 |
Coltellic PA |
| PHARM-60 |
Erivedge PA |
| PHARM-61 |
Imlygic PA |
| PHARM-62 |
Keytruda PA |
| PHARM-63 |
Odomzo PA |
| PHARM-64 |
Opdivo PA |
| PHARM-65 |
Tafintar PA |
| PHARM-66 |
Yervoy PA |
| PHARM-67 |
Zelboraf PA |
| PHARM-68 |
Mekinist PA |
| PHARM-69 |
Cinqair PA |
| PHARM-70 |
Kisqali PA |
| PHARM-71 |
Spinraza PA |
| PHARM-72 |
Vosevi PA |
| PHARM-73 |
Nerlynx PA |
| PHARM-74 |
Mavyret Initiation - Draft |
| 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 |