Okla Hca Sc-10 - State Of Oklahoma Soonercare/oepic Ip Referral Form
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1State of Oklahoma
Oklahoma Health Care Authority
SoonerCare/OEPIC IP Referral Form
Please Print
Member Name
Last Name
First Name
Middle Initial
Member ID#
Member
(nine digits)
Phone #
Referred To:
Provider Name
Provider
(Must be a current
Phone #
Medicaid Provider)
Provider Address
PCP/CM Referral Valid
Initial Visit Only
Evaluation & Treatment for _________ months (cannot
for (check one)
exceed 12 months)
Diagnosis
1
2
3
(Use ICD-9 Codes)
Reason for
Referral:
Referred by:
Primary Care Provider/
PCP/CM
Case Manager Name
Phone #
Signature of Referring
Provider
Date
PCP/CM # Referral
NPI #
Number (ten digits)
* This referral is valid for all ancillary services related to the above diagnosis within the specified time frame.
* This referral may be forwarded to other specialists for the above diagnosis with the approval of the PCP/CM.
* Report your findings directly to the provider who made this referral.
* This referral number should be entered by the referred to provider in Block 17a and NPI in Block 17b of the CMS-1500 claim form or
Block 83B of the UB 92 claim form.
* This form is for referral only. It does not replace the prior authorization form. Some services for SoonerCare/OEPIC IP clients
require (1) PCP/CM referral and (2) prior authorization from the Medical Authorization Unit at Oklahoma Health Care Authority. The current
prior authorization policies are unchanged (See Oklahoma Health Care Authority Rules).
* All payments for services are subject to coverage limitations under the current Medicaid/OEPIC IP program and the referral is not a
guarantee of payment.
Instructions:
1. Complete and mail the original copy of the form to the provider to whom you are referring.
2. Keep a duplicate copy for your records in the member's medical chart.
3. Referral form (SC-10) may be obtained on the OHCA web site at
PLEASE DO NOT MAIL OR FAX A COPY TO OHCA.
PLEASE DO NOT ATTACH A COPY TO YOUR CLAIM FORM.
OKLA HCA Revised 10-1-06
SC-10
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