Skip to main content

Due to heightened security alerts near the state capitol, OHCA will cancel the Jan. 20, 2021 board meeting and reschedule for next week. The safety of OHCA employees, board members and partners is of paramount importance. Once confirmed, the new date and time will be posted here.

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
 24 Month Visit
 CH-11
 30 Month Visit
 CH-12  3 Year Old Visit
 CH-13  4 Year Old Visit
 CH-14  5 Year Old Visit
 CH-15  6 to 10 Year Old Visit
 CH-16  11 to 20 Year Old Visit
 CH-17 English - Spanish Psychosocial Assessment
 CH-18  "5As" Tobacco Cessation Counseling Form
 Tobacco Cessation Benefits Explained
 Dental - Caries Risk Assessment Form Ages 0-6    Caries Risk Assessment Form Ages 0-6  
Dental - Caries Risk Assessment Form 7+   Caries Risk Assessment Form Ages 7+  
 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 *The HCA-17 form is no longer effective as of Jan. 1, 2021. OHCA implemented a new electronic process for these claims which are now submitted through the provider portal. You may find instructions on our Training Page
 HCA-18  Request for Duplicate Provider Remittance Statement 
 HCA-20 English - Spanish  Authorization to Release Medicaid Records
 HCA-24  Care Coordination Referral Form
 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 Ages 4-20
 HCA-52A  Adult Incontinence Supply Form Ages 21 and above  
 HCA-60  Prior Authorization Amendment Form 
 HCA-61  Therapy Prior Authorization Request Form  
 HCA-64  Meals and Lodging Request Form
 HCA-65  Out of State Prior Authorization Request
 HCA-NB1 Reporting of Newborn Child of SoonerCare Member
 Insure Oklahoma  Insure Oklahoma Children Form
 LD-1 English | Spanish  Member Complaint/Grievance Form
 LD-2  Provider/Physician Grievance Form
 LD-3  Provider/Physician Appeal Form  
 LD-5 English | Spanish  Member Step Therapy Appeals 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-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
Last Modified on Jan 21, 2021
Back to Top