Provider Referral Form

Use this Form to refer a member to Oklahoma Complete Health for a care manager for assistance with linkage, coordination, and advocacy.

Date:

To:

From: *

Member Name: *

Medicaid ID # : *

Member Phone Number: *

Member Address 1:

Member Address 2:

City:

State:

Zip Code:

Provider Name: *

Fax # :

Please check the reason for the Referral: * Behavioral Health (screening scored positive) No Show (minimum of 2) High Emergency Room usage Needs a specialist Other (please explain)

Other:

Please give details as to the reason for the referral: *

Last Updated: 03/19/2025