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-01   EHR Flexibility Rule 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  
 PHARM-33    Harvoni Initiation  
 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