Skip to main content

Call the helpline at 800-987-7767, option 5, and talk to choice counselors to change your SoonerSelect health plan!


Form number Title
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
24 Month Visit
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-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-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 
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-2 Provider Program Integrity Audit Appeal Form
LD-3 Provider/Physician Appeal Form
LD-4 In-Person Hearing Request
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 Submission Form


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
Last Modified on Apr 04, 2024
Back to Top