Before submitting your application electronically, you must agree to the terms below. You must
select "I agree" to complete the application.
I agree to:
- Help the Oklahoma Health Care Authority check any and all information on this application, and let them get needed information from government agencies, employers, medical providers and other sources.
- Help the Oklahoma Department of Human Services or the Oklahoma Health Care Authority identify and find absent parents who might be liable for the costs of medical care to me or others in my family receiving SoonerCare.
- Tell the Oklahoma Health Care Authority within 10 days if there are any changes in our income, the people who live in our home, where we live or get our mail, and/or our health insurance.
I will allow SoonerCare to:
- Collect payments from anyone who is supposed to pay for medical care.
- Share necessary medical information with any insurance company, person or entity who is responsible for paying the bill.
- Inspect any of my medical records to see if claims for services can be paid.
I will allow any of my medical providers or home care providers to:
- Give information to the OK Department of Human Services or the Oklahoma Health Care Authority to make payment or overpayment decisions.
The information I give on this form is true and correct to the best of my knowledge. I am the person electronically signing this application. I understand that if I give information that isn’t true OR if I withhold information, I can be lawfully punished for fraud or perjury. I may also have to re-pay SoonerCare for any medical bills, which were not paid correctly.
You must electronically sign your application by selecting your name from the list provided. When you have finished, select "Submit" to submit your application.
Name of the person signing the application