After July 31, 2018, OHCA will no longer be accepting Living Choice Referrals due to the closing of the program.

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:
(xxx-xxx-xxxx)
*Current Address: *SSN:
(xxx-xx-xxxx)
*City: *State: *Zip:
County:
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:
(xxx-xxx-xxxx)
Family Contact Information:
First Name: Last Name: Phone:
(xxx-xxx-xxxx)
Relationship:
Institutional Information: (Living Choice Only)
Name of Institution where you now live:
Room: Provider ID:
Address:
City: State: Zip:
Personal Physician's Information:
First Name:

Last Name: Admission Date:
Referral Information:
*How did you hear about the program:
*Person making referral:
*First Name: *Last Name: *Phone:
(xxx-xxx-xxxx)
*Relationship:
If "Person making referral" is "Other" then explain: