| Form number |
Title |
Format |
| 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 |
2 Year Old Visit |
|
| CH-11 |
3 Year Old Visit |
|
| CH-12 |
4 Year Old Visit |
|
| CH-13 |
5 Year Old Visit |
|
| CH-14 |
6 to 10 Year Old Visit |
|
| CH-15 |
11 to 20 Year Old Visit |
|
| CH-16 English |
Psychosocial Assessment |
|
| CH-16 Spanish |
Psychosocial Assessment |
|
| CH-17 |
High Risk Ob Form |
|
| CH-18 |
5As Tobacco Cessation Counseling Form |
|
| DEN-01 |
Confirmation of Pregnancy Form |
|
| FIN-01 |
Disproportionate Share Hospital Worksheet |
 |
| FPWS-01 |
Application for Family Planning Services |
|
| HCA-3 |
Elective Sterilization Consent |
|
| HCA-3A |
Hysterectomy Acknowledgement |
|
| HCA-3B |
Certificate for Abortion |
|
| HCA-12A |
Prior Authorization |
|
| HCA-13 |
Coversheet for paper attachment to electronic claim |
|
| HCA-13A |
Coversheet for paper attachment to prior authorization |
|
| HCA-13-1 |
Timely Filing Information |
|
| HCA-14 |
UB92 and Inpatient/Outpatient Crossover Adjustment Request |
|
| HCA-15 |
Paid Claim Adjustment Request for Crossover Part B, Dental, CMS 1500 |
|
| HCA-17 |
Claim Inquiry Response |
|
| HCA-18 |
Request for Duplicate Provider Remittance Statement (beyond 60 days) |
|
| HCA-20 Spanish |
Authorización para reveler el expendiente medico |
|
| HCA-20 English |
Authorization to Release Medicaid Records |
|
| HCA-24 |
Care Management Referral |
|
| HCA-25 |
Medical Necessity for Air Transport |
|
| HCA-27 |
Physician’s Certification Statement |
|
| HCA-28 |
Medicare-Medicaid Crossover Invoice |
|
| HCA-29 |
Certificate of Medical Necessity - External Infusion Pump |
|
| HCA-30 |
Certificate of Medical Necessity - Hospital Beds |
|
| HCA-31 |
Certificate of Medical Necessity - Motorized Wheelchair |
|
| 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-35 |
Certificate of Medical Necessity - Seat Lift Mechanisms |
|
| HCA-36 |
Certificate of Medical Necessity - Respiratory Assist Device - CPAP and BIPAP |
|
| HCA-37 |
Certificate of Medical Necessity - Support Surfaces |
|
| HCA-38 |
Certificate of Medical Necessity - Enteral and Parenteral Nutrition |
|
| HCA-39 |
Certificate of Medical Necessity - Transcutaneous Electrical Nerve Simulator (TENS) |
|
| HCA-40 |
Ambulance Transportation Form |
|
| HCA-41 |
Meal and Lodging Order - Tickets |
|
| HCA-41A |
Meal and Lodging Authorization Form |
|
| HCA-41B |
Supplemental Meal and Lodging Order Form |
|
| HCA-42 |
SoonerCare Patient Dismissal request Form |
|
| HCA-NB1 |
Issued 6-7-07 |
|
| HLD-1 |
Orthodontia |
|
| LD-1 |
Member Complaint/Grievance Form |
 |
| LD-2 |
Provider/Physician Grievance Form |
|
| LD-5 |
Form Memo Regarding Appellants in SURS Cases |
|
| LTC-10 |
Nurse Aid Training Reimbursement Worksheet |
|
| LTC-300 |
ICF-MR Level of Care Assessment Form with Instructions |
|
| LTC-300A |
PASRR Level I Screen Form and Instructions |
|
| LTC-300R |
Nursing Facility Level of Care Assessment |
|
| LTC-300R |
Nursing Facility Level of Care Assessment Guidelines for Completion |
|
| OSF-20A |
Request for Replacement of Warrant |
|
| OSF-20B |
Request for Replacement Affidavit |
|
| PHARM-01 |
Pharmacy Claim |
|
| PHARM-02 |
Compound Prescription Drug Claim |
|
| PHARM-03 |
Pharmacy Paid Claim Adjustment Request |
|
| PHARM-04 |
Universal Petition for Medication Authorization |
|
| PHARM-06 |
Petition for Tuberculosis Related Therapy Authorization |
|
| PHARM-07 |
Petition for Synagis Authorization |
|
| PHARM-07S |
Supplmental Synagis Dosing Form |
|
| PHARM-08 |
Medication Therapy Management Services Prior Authorization Request |
|
| PHARM-09 |
Medication Therapy Management Services Referral Form |
|
| PHARM-11 |
Statement of Medical Necessity for Brand-Name Drug Override |
|
| PHARM-12 |
Statement of Medical Necessity for Early Fill Override |
|
| PHARM-13 |
Statement of Medical Necessity for Quantity Limit Override |
|
| PHARM-14 |
Statement of Medical Necessity for Xolair |
|
| PHARM-16 |
Pharmacy Lock-In Referral |
|
| QOCR |
Quality of Care |
|
| SC-10 |
SoonerCare Choice Referral Form with Guidelines and Instructions |
|
| SC-11 |
SoonerCare Choice Provider Change Request |
|
| SC-12 |
Issued 02-01-08 Provider Training Request Form |
|
| TPL-1 |
Third Party Liability Information Sheet |
|