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  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-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 Management Referral
 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-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
 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