| Form number | Title |
|---|
| 02HM003E | Uniform Comprehensive Assessment (Part III) - Medical Assessment |
| 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 | Psychosocial Assessment
English | Spanish |
| 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-6 | Handicapping Labio-Lingual Deviation (HLD) Index Form |
| DEN-7 | Dental Prior Authorization Amendment |
| FIN-01 | Disproportionate Share Hospital Worksheet |
| HCA-3 | Elective Sterilization Consent
English | Spanish |
| HCA-3A | Hysterectomy Acknowledgement
English | Spanish |
| 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 | *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
| Authorization to Release Medicaid Records
English | Spanish |
| HCA-24 | Care Coordination Referral Form |
| HCA-27 | Physician’s Certification Statement |
| 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-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
English | Spanish |
| HCA-52A | Adult Incontinence Supply Form Ages 21 and above |
| HCA-53 | State Plan Personal Care - Communication |
| HCA-54 | State Plan Personal Care - Service Plan |
| HCA-55 | State Plan Personal Care - Planning Schedule and Service Plan |
| HCA-56 | State Plan Personal Care - Progress Note |
| HCA-57 | State Plan Personal Care - Care Plan |
| 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-67 | Certification For Medicaid Funded Abortion |
| HCA-68 | Donor Human Milk Request Form |
| LD-1 | Member Complaint/Grievance Form
English | Spanish |
| LD-1S | Request for State Fair Hearing |
| LD-2 | Provider Program Integrity Audit Appeal Form |
| LD-3 | Provider/Physician Appeal Form |
| LD-4 | In-Person Hearing Request
English | Spanish |
| LD-5 | Member Step Therapy Appeals Form
English | Spanish |
| LTC-11 | PACE Waiver Request Form
|
| LTC-12 | PACE Request for Deeming of Continued Eligibility |
| LTC-300 | ICF-ID 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 |
| NODOS/NB1 | NODOS/NB1 Submission Form
|
| OSF-20R | Warrant Replacement Request
|
| PPC Form | Provider Preventable Conditions |
| Pharmacy Forms |
| Qualifying Clinical Trial Attestation |
| QOCR Instructions | QOCR Instructions |
| QOCR | Quality of Care |
| SC-10 | SoonerCare/Insure Oklahoma Referral Form |
| SC-14 | SoonerCare Administrative Referral Request |
| SC-15 | Parental Consent Form
English | Spanish |
| SC-16 | Change of Provider Request
English | Spanish |
| TPL-1 | Third Party Liability Information Sheet |
| TPL-2 | TPL-1 and TPL-9008-W Cover Sheet |
