Sc 10 form 2025

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The document is a referral form for SoonerCare/Insure Oklahoma, used by medical providers to refer members to other healthcare providers. It includes fields for member and provider information, referral details, and instructions for processing the referral. The form emphasizes that referrals are valid for ancillary services related to the specified reason and outlines payment coverage limitations.

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Click ‘Get Form’ to open the SC 10 form in the editor.
Begin by entering the Member Name, including Last Name, First Name, and Middle Initial. Ensure accuracy for proper identification.
Input the Member ID and Member Phone number. This information is crucial for communication regarding the referral.
Fill in the Member's Date of Birth in the specified format (00/00/0000).
In the 'REFERRED TO' section, provide the Provider Name, Phone, Fax, and Address. Make sure this is a current SoonerCare provider.
Specify the Referral Valid dates. The start date should not exceed six months retrospectively, while the end date cannot exceed twelve months total.
Clearly state the Reason for Referral to ensure appropriate services are rendered.
Complete the 'REFERRED BY' section with your Medical Home Provider Name and their contact details.
Finally, sign and date as the Referring Provider, including your ID Number and NPI# (10 digits).

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