Forms

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
Tobacco Cessation Benefit One-Pager
 
DEN-1  Confirmation of Pregnancy Form 
DEN-2  Orthodontic Treatment 
DEN-3  Change of Dental Provider Request 
DEN-4      Orthodontic Expectations Agreement 
DEN-5  Ortho Dismissal Request Form 
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-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-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-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-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  Prior Authorization Form: Makena® (17-hydroxyprogesterone caproate) 
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 Therarpy Intent to Treat Contract 
PHARM-29  Hepatitis C Therapy Pharmacy Agreement 
PHARM-30  Hepatitis C Therapy Continuation  
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 English | Spanish  Parental Consent Form 
SC-16 English | Spanish  Change of Provider Request 
TPL-1  Third Party Liability Information Sheet