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Forms and Guides

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Forms

Authorization to Release medicaid Records - English | Spanish
Common Injury Accident Questions and Answers
Income Verification Form - English | Spanish
End of Life Legal Forms - English | Spanish
Health Insurance Marketplace Application - English | Spanish
IRS 1095-B Form
Lottery Gambling Winnings Monthly Income
Member Complaint/Grievance Form (LD-1) - English | Spanish
Member Step Therapy Appeals Form (LD-5) - English | Spanish
No Income Attestation Form - English | Spanish
Request for Fair Hearing
Request for State Fair Hearing (LD-1s)
Request for Telephonic Hearing (LD-4) - English | Spanish
Retroactive Eligibility Application for SoonerCare - English | Spanish
Self-Employment/Cash Income Statement - English | Spanish
Transitional Medical Assistance Reporting - English | Spanish
12 Month Profit and Loss Worksheet - English | Spanish
Voter Registration

Other Documents

EPSDT – A Guide to Keeping Your Kids Healthy/SoonerCare Member Guide - English | Spanish
MAGI (Income Fact Sheet) - English | Spanish
Referral Guide for SoonerCare Members - English | Spanish
Document Verification Guide - English | Spanish
SoonerCare Member Handbook - English | Spanish
SoonerCare FAQs - English | Spanish
SoonerPlan Family Planning Brochure

Oklahoma Health Care Authority

4345 N Lincoln Blvd

Oklahoma City, OK 73105

Contact Us

The Oklahoma Health Care Authority collects the personally identifiable data submitted and received in regard to applications for services, renewals, appeals, provision of health care and processing of claims. This data is treated as confidential and is stored securely in accordance with applicable law and regulations. OHCA may share this personally identifiable data with its authorized business associates, government agencies with jurisdiction over the OHCA, or as otherwise required or permitted by applicable law.