Change of Provider

Prior Authorization form

Form must be completed in its entirety or will not be accepted
Effective date of change will depend on current billing cycle
This form may only be signed by the member, the parent/legal guardian, or the attorney-in-fact
Facilities and their representatives are not acceptable signatures on the Change of Provider Request Form

Member Name *

Member RID # *

Service Being Rendered *

I (print name of member/parent/legal guardian), *

hereby wish to change the above listed services being provided by (print name of previous provider)

to print name of new provider

Effective

(Date the change is to take place)

Signature of Member of Parent/Legal Guardian if a minor *

Clear

Date Signed by Member/Parent/Legal Guardian

Relationship to Member

**Please Note: OHCA 317:30-3-14(a) states "The Oklahoma Health Care Authority (OHCA) assures that any individual eligible for SoonerCare, may obtain services from any institution, Agency, pharmacy, person, or organization that is contracted with OHCA and qualified to perform the services."

OHCA Revised 2-3-16 SC-16