Long-Term Care Waiver Operations

Create New Referral Case:
Personal Information:
*Last Name: *First Name: Medicaid Number:
This field is also known as Member Number or SoonerCare ID
*DOB: *Sex: *Phone:
*Current Address: *SSN:
*City: *State: *Zip:
Do you have a legal guardian/power of attorney with medical decision making authority:
If yes, name of legal guardian/power of attorney:
First Name: Last Name: Phone:
Family Contact Information:
First Name: Last Name: Phone:
Please fax all Legal Guardian and/or Power of Attorney Documents to: (405) 530-7265
Institutional Information: (Living Choice Only)
Name of Institution where you now live:
Room: Provider ID:
City: State: Zip:
Personal Physician's Information:
First Name:

Last Name: Admission Date:
Please fax all medical records to (405) 530-3475
Referral Information:
*How did you hear about the program:
*Person making referral:
*First Name: *Last Name: *Phone:
If "Person making referral" is "Other" then explain: