Waiver Operation - Referral

	WAIVER OPERATIONS

Long Term Services and Supports

Create New Referral Case:

Personal Information:

*Last Name:

*First Name:

Medicaid Number:

This field is also known as Member Number or SoonerCare ID

*DOB:

Open the calendar popup.

*Sex:

*Phone:

(xxx-xxx-xxxx)

*Current Address:

*SSN:

(xxx-xx-xxxx)

*City:

*State:

*Zip:

County:

* 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:

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:

Zip:

Personal Physician's Information:

First Name:

Last Name:

Admission Date:

Open the calendar popup.

Please fax all medical records to (405) 530-3475

Referral Information:
*How did you hear about the program:
*Person making referral:
*First Name:	*Last Name:	*Phone:	(xxx-xxx-xxxx)
*Relationship:
If "Person making referral" is "Other" then explain: