WAIVER OPERATIONS
Long Term Services and Supports
Create New Referral Case:
- Select -
Living Choice
Medically Fragile
Personal Information:
*
Last Name:
*
First Name:
Medicaid Number:
This field is also known as Member Number or SoonerCare ID
*
DOB:
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*
Sex:
- Select -
Male
Female
*
Phone:
(xxx-xxx-xxxx)
*
Current Address:
*
SSN:
(xxx-xx-xxxx)
*
City:
*
State:
- Select -
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
PL
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
*
Zip:
County:
- Select -
Adair
Alfalfa
Atoka
Beaver
Beckham
Blaine
Bryan
Caddo
Canadian
Carter
Cherokee
Choctaw
Cimarron
Cleveland
Coal
Comanche
Cotton
Craig
Creek
Custer
Delaware
Dewey
Ellis
Garfield
Garvin
Grady
Grant
Greer
Harmon
Harper
Haskell
Hughes
Jackson
Jefferson
Johnston
Kay
Kingfisher
Kiowa
Latimer
LeFlore
Lincoln
Logan
Love
McClain
McCurtain
McIntosh
Major
Marshall
Mayes
Murray
Muskogee
Noble
Nowata
Okfuskee
Oklahoma
Okmulgee
Osage
Ottawa
Pawnee
Payne
Pittsburg
Pontotoc
Pottawatomie
Pushmataha
Roger Mills
Rogers
Seminole
Sequoyah
Stephens
Texas
Tillman
Tulsa
Wagoner
Washington
Washita
Woods
Woodward
Arkansas
Kansas
*
Are you a member of a federally recognized tribe? If so, which one:
*
Have you ever received health care services at any tribal or Indian Health Service (IHS) facility? If so, which one:
*
Do you have a legal guardian/power of attorney with medical decision making authority:
- Select -
Yes
No
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:
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:
Address:
City:
State:
- Select -
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
PL
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
Personal Physician's Information:
First Name:
Last Name:
Admission Date:
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October 2024
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October 2024
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Please fax all medical records to (405) 530-3475
Referral Information:
*
How did you hear about the program:
- Select -
Self
Family Member
Nursing Facility
Other
MDS 3.0
Media
Case Manager
*
Person making referral:
- Select -
Self
Family Member
Nursing Facility
Other
MDS 3.0
Media
Case Manager
*
First Name:
*
Last Name:
*
Phone:
(xxx-xxx-xxxx)
*
Relationship:
If "Person making referral" is "Other" then explain: