Form number Title
 After Hours   After Hours Participation Form
 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 - Spanish Psychosocial Assessment
 CH-17 High Risk Ob Form
 CH-18  "5As” Tobacco Cessation Counseling Form
Tobacco Cessation Benefit One-Pager
 DEN-1  Confirmation of Pregnancy Form
 DEN-2  Orthodontic Treatment
 DEN-3  Change of Dental Provider Request
 DEN-4       Orthodontic Expectations Agreement
 DEN-5  Ortho Dismissal Request Form
 EHR-01  EHR Flexibility Rule Form
 EHR - 02  EHR-Hospital Payment Documentation Form
 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
 Dental 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  Claim Inquiry Response
 HCA-18  Request for Duplicate Provider Remittance Statement 
 HCA-20 English - Spanish  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-32    Certificate of Medical Necessity - Oxygen  
 HCA-33  Certificate of Medical Necessity - Pneumatic Compression Devices
 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-42  SoonerCare Patient Dismissal request Form
 HCA-43  Physician Statement for Therapeutic Shoes
 HCA-44  OHCA Telemedicine Consent Form
 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  
 HCA-NB1  Issued 6-7-07
 HLD-1  Orthodontia
 Insure Oklahoma  Insure Oklahoma Children Form
LCP   Living Choice Project Forms 
LD-1 English | Spanish  Member Complaint/Grievance Form
 LD-2  Provider/Physician Grievance Form
 LD-5  Form Memo Regarding Appellants in SURS Cases
 LTC-7  LTC-7 Level of Care Determination
 LTC-10  Nurse Aid Training Reimbursement Worksheet
 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
 OSF-20A  Request for Replacement of Warrant
 OSF-20B  Request for Replacement Affidavit
 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-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-14A  Statement of Medical Necessity for Xolair for Asthma  
 PHARM-14B  Statement of Medical Necessity for Xolair for Chronic Idiopathic Urticaria  
 PHARM-16  Pharmacy Lock-In Referral
 PHARM-17  ESA Petition
 PHARM-18  Outpatient Medication Petition
 PHARM-20  Growth Hormone PA
 PHARM-23  Prior Authorization Form: Makena® (17-hydroxyprogesterone caproate) 
 PHARM-24  Botulinum Toxins
 PHARM-25  State of Medical Necessity for Ingredient Duplication Override
 PHARM-26  Sovaldi Initiation
 PHARM-27  Olysio Initiation
 PHARM-28  Hepatitis C Therapy Intent to Treat Contract
 PHARM-29  Hepatitis C Therapy Pharmacy Agreement
 PHARM-30  Hepatitis C Therapy Continuation  
 PHARM-33    Harvoni Initiation  
 PHARM-34  Viekira Pak Initiation
 PHARM-35  Diabetic Supplies PA  
 PHARM-36  Technivie Initiation  
 PHARM-37  Daklinza Inititiation  
 PHARM-38    PCSK9 Inbitor PA  
 QOCR Instructions  QOCR Instructions
 QOCR  Quality of Care
 SC-10  SoonerCare Choice Referral Form with Guidelines and Instructions
 SC-12  Issued 02-01-08 Provider Training Request Form
 SC-13  SoonerCare Choice Provider Change Request (Formally SC-11- PDF still titled SC-11)
 SC-14  SoonerCare Referral Request
SC-15 English | Spanish  Parental Consent Form 
SC-16 English | Spanish  Change of Provider Request 
 TPL-1  Third Party Liability Information Sheet