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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 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-6  Handicapping Labio-Lingual Deviation Index of Malocclusion  
 DEN-7  Dental Prior Authorization Amendment
 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-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-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
 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-67 Certification For Medicaid Funded Abortion  
 HCA-68 Donor Human Milk Request Form
 LD-1 English | Spanish  Member Complaint/Grievance Form
 LD-2  Provider/Physician Appeal Form
 LD-3  Provider/Physician Grievance Form  
LD-4 In-Person Hearing Request
 LD-5 English | Spanish  Member Step Therapy Appeals Form
 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

NODOS/NB1 Submission Form


 Warrant Replacement Request

 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 English | Spanish  Parental Consent Form 
SC-16 English | Spanish  Change of Provider Request 
 TPL-1  Third Party Liability Information Sheet
Last Modified on Dec 20, 2022
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