Common Intake Form
- Please review the eligibility requirements (If eligible, proceed to #2)
- Please take the time to complete the form fully for consideration.
- You will need to have the participant’s SoonerCare ID and SSN
- If participant has a Court ordered Legal Guardian or a Court ordered Medical Decision Power of Attorney, please provide the name and contact information.
- Submit form using the send button or print off form and fax to 405-530-7265 for Living Choice and 405-530-7736 for Medically Fragile.
- All referral forms are subject to a background check with Adult Protective Services (APS) for further program consideration
- Allow 5-7 business days for follow-up
If you have questions or feedback, please call us at 888-287-2443 or send us an email to firstname.lastname@example.org