Get Forms - Ohca

Filling out the Forms - OHCA is an essential process for providers seeking a settlement agreement with the Oklahoma Health Care Authority. This guide will provide you with a clear, step-by-step approach to complete the online form accurately.

Follow the steps to successfully complete the Forms - OHCA.

1. Click 'Get Form' button to obtain the form and open it for editing.
2. Provide the required provider information, including the provider name and SoonerCare ID. Ensure that the SoonerCare ID for the group is included if applicable.
3. Fill in the ICN (Internal Control Number) or OHCA claim number. This is essential for tracking the request.
4. Indicate the reason for requesting the settlement agreement by selecting the appropriate option. If applicable, provide the date that the provider's contract expired or detail other reasons, including service dates.
5. Include the signature of the provider or the provider representative. Ensure that their name and title are clearly written for identification.
6. Designate a point of contact for any inquiries regarding the settlement request by including their name, telephone number, and email.
7. Review the completed form thoroughly to ensure all fields are filled out accurately, and all necessary documentation is included.
8. Once reviewed, submit the completed and signed Request Form by fax to 405-530-3224 or email to ProviderEnrollment@okhca.org.
9. Remember to save changes to your form, and consider downloading, printing, or sharing a copy for your records.

Start completing your Forms - OHCA online today to facilitate your settlement agreement request.