| 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 Index of Malocclusion |
| 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-13 |
Provider Action 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 |
