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SoonerCare/OEPIC IP Referral Form
SoonerCare/OEPIC IP Referral Form
Please fill out the form below so we know how best to communicate with you. Contact information will NOT be shared or sold to any third parties under any circumstances. * are required.
Personal Information
* Last Name
* First Name
Middle Initial
ID#
(nine digits)
Phone
* Email
Referred To
Provider Name
Phone #
Provider Address
PCP/CM Referral Validfor (check one)
Initial Visit Only
Evaluation & Treatment
Diagnosis
(Use ICD-9 Codes)
1
2
3
Reason for Referral
Referred by
Primary Care Provider/
Case Manager Name
PCP/CM Phone #
Signature of Referring Provider
Date
PCP/CM # Referral Number (ten digits)
NPI #
* Verification
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.
