Benefits and Forms
Use this booklet to help you understand your new health plan and benefits.
That way you can focus on being healthy!
LOOK INSIDE TO FIND:
Healthcare Services
Value-Added Services
Where to go for Care
How to Earn Rewards
How to Find a Primary Care Provider (PCP)
Important Health Forms
QUESTIONS? Call 1-833-752-1664 (TTY: 711), Monday through Friday, from 8 a.m. to 5 p.m.
or go to OklahomaCompleteHealth.com any time.
CAD_135999E State Approved 10312023
© 2023 Oklahoma Complete Health. All rights reserved.
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OklahomaCompleteHealth.com
Make Oklahoma Complete Health Part of Your Plan
Oklahoma Complete Health provides quality healthcare coverage with valuable programs and services.
That way you and your family can focus on being healthy. Use this booklet to get the most out of your insurance.
Keep it handy for helpful information about your health plan.
What’s Inside:
Healthcare Services 2
Transportation 3
Value-Added Services 4
Your Online Member Portal Account 9
Where to Go for Care 10
Your Care When You Change Health Plans or Doctors 12
Tell Us About Your Health 14
Start Earning Rewards
15
Finding a Primary Care Provider (PCP) 16
Notification of Pregnancy (NOP) 18
Notice of Non-Discrimination 19
Notice of Privacy Practices 27
Forms and Envelope 33
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GO ONLINE:
• Go to Member.OklahomaCompleteHealth.com to set up your online member portal account.
• See your health plan benefits.
• Access other important information, such as your ID card, claims, authorizations, and more.
IF YOU DO NOT HAVE INTERNET ACCESS:
• Read this booklet and other member materials included in this packet.
• Fill out the forms located in the back of this booklet and mail them using the postage-paid envelope.
• Call Member Services at 1-833-752-1664 (TTY: 711) for help finding a Primary Care Provider (PCP) or
to answer any other questions you may have.
If you need oral interpretation, auxiliary aids and services, or this information in another language or an alternate
format call us at 1-833-752-1664 (TTY: 711).
1
USE THIS LIST TO HELP YOU GET STARTED
Follow the steps below. Fill out any forms that are needed. Then, check the boxes as you finish each step.
Learn More About Your Benefits
Find important information about your benefits and services inside this booklet and in the Oklahoma
Complete Health member handbook. The handbook is located at OklahomaCompleteHealth.com
under the member section. If you would like a printed copy, call Member Services at
1-833-752-1664 (TTY: 711). Additional copies of the Member Handbook will be sent upon request.
Set Up Your Member Portal Account
Set up your online member portal account using the steps on page 9.
Login:
Password:
Keep this in a safe place.
Complete Your My Health Screening Form
The My Health Screening form helps us stay updated about your healthcare needs. We use this
form to find out about any health changes you’ve had. That’s why it’s important to complete this
form every year. By having this information, we can meet your specific health needs with more
services or resources.
Please fill out the form located in the back of the booklet and return it using the postage-paid
envelope. You can also complete the form online by scanning the QR code on the form, or on
our website at Member.OklahomaCompleteHealth.com through your member portal.
Start Earning Rewards
Oklahoma Complete Health members can earn rewards just for staying healthy!
Go to OklahomaCompleteHealth.com or turn to page 15 to learn more about
.
Make an Appointment to See Your Primary Care Provider (PCP)
PCP name:
Address:
Phone: Email:
Office Hours: First Appointment Date:
Change your PCP at Member.OklahomaCompleteHealth.com.
Notification of Pregnancy
If you are pregnant, please complete the Notification of Pregnancy (NOP) form. Fill it out online
through the member portal at OklahomaCompleteHealth.com. Or use the one included in
the back of the booklet and return it to us using the postage-paid envelope. Earn $25 in
rewards for filling out the form in your first trimester or $10 for filling it out in
your second trimester. During your pregnancy and postpartum period, earn $25 for completing
one Start Smart for Your Baby
®
prenatal visit and $10 for competing one postpartum visit.
Call your OB case manager for more details.* *Restrictions may apply
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Oklahoma Complete Health offers a wide range of
healthcare services.*
*Limitations apply.
MEDICAL SERVICES:
• Provider office visits.
• Medication.
• Labs.
• X-rays.
• Home healthcare.
• Hospital admissions.
• Medical supplies.
VISION SERVICES:
• Eye exams.
• Eyeglasses.
Learn More About Your Coverage
This is only an overview of services. Check your benefits to see if a certain medical, vision,
or behavioral health service is covered.
Transportation
BEHAVIORAL HEALTH AND
SUBSTANCE ABUSE SERVICES:
• Applied Behavioral Analysis (how behavior works
to real-life situations).
• Therapy, family support, and training.
• Individual, group, and family counseling services.
• Certified Community Behavioral Health
(CCBH) services.
• Inpatient psychiatric evaluation and treatment.
• Substance use disorder screening and treatment,
including addiction services and help with
withdrawal symptoms.
• Mental health services provided in a
residential setting.
• Partial hospitalization.
• Day treatment services.
• Peer recovery support services.
• Rehabilitation case management.
OklahomaCompleteHealth.com | 1-833-752-1664 (TTY: 711)
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Learn More About Your Coverage
Emergency:
Transportation
If you need emergency transportation, such as an ambulance, call 911.
Non-emergency:
Oklahoma Complete Health can arrange for transportation to help
you get to and from your Medicaid-covered care appointments.
This service is at no cost to you. Non-emergency transportation
includes personal vehicles, taxis, vans, and public transportation.
Call transportation services at 1-877-718-4212 to make a
reservation. You must call at least 72 hours before your
appointment, excluding weekends and state holidays.
Value-Added Services
Oklahoma Complete Health members are eligible
for the extra benefits listed below:
Benefit Description
Boys & Girls Club Memberships
Oklahoma Complete Health provides Boys & Girls Clubs memberships
to members ages 6-18 years old.
Breathe Better at Home
Oklahoma Complete Health provides asthma self-management
through these benefits:
• Home visits by a care manager or community health worker to
check the home for environmental triggers.
• In-home asthma management education and tobacco
cessation resources.
• Care grants of up to $250 per year per member to support
home-based remediation of asthma triggers (e.g., hypoallergenic
bedding, pest control, carpet cleaning, cleaners low in volatile
organic compounds, etc.).
• Additional nebulizer for members ages 0-18 years old.
ConnectionsPlus
®
Through our ConnectionsPlus
®
program, Oklahoma Complete Health
provides no-cost cell phones and data plans to members in care
management who do not have safe, reliable access to phone or web
services, to those who do not qualify for the federal SafeLink Wireless
®
.
ConnectionsPlus
®
lets members have access to providers, care
managers, telehealth services, and 911.
Digital Behavioral Health
(BH) App
Oklahoma Complete Health provides members ages 13 and older
with access to myStrength
®
Complete, our digital BH app for health
education and coaching. myStrength
®
has personalized online tools
and coaching to help members with depression, anxiety, stress,
substance use, chronic pain, and sleep problems. Members can use
the app through our website any time.
myStrength
®
also supports the physical and spiritual aspects of
whole-person health. Members ages 18 and older may also access two
more items through myStrength
®
Complete:
• Virtual BH provider visits.
• Choose Tomorrow suicide prevention support.
OklahomaCompleteHealth.com | 1-833-752-1664 (TTY: 711)
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5
Value-Added Services
Benefit Description
Educational Support
and Work Skills
Oklahoma Complete Health offers three benefits to help members
improve their grades in school or get their diploma or GED.
Benefits include:
• For members ages 16 and older without a high school diploma,
we provide GED tutoring and vouchers for testing.
• For qualified members in grades K-12, we provide in-person or
virtual tutoring to eligible youth in care management who are at risk
of failing one or more core subject areas.
• For adult members in care management, we offer scholarships to
attend Rose State College for a Community Health Worker (CHW)
micro-certification.
Enhanced
Transportation
Services
Oklahoma Complete Health offers these enhanced transportation
benefits through our transportation partners:
• We provide one trip per day to parents or guardians to visit a child
inpatient in the hospital.
• We provide five roundtrips per member per year to help members
get to grocery stores, food pantries, farmer’s markets, childcare
services, job interviews, educational activities, and support groups.
• We let minor siblings join non-emergency medical transportation
rides to EPSDT, primary care, and urgent care appointments.
Health, Wellness,
and Health Literacy
Oklahoma Complete Health helps members take charge of their
health, learn about their conditions, and engage in healthy behaviors.
Our benefits include:
• No-cost access to our online health library, which has more than
4,000 easy-to-read articles. Members can learn about wellness,
illnesses, care plans, medications, and other health tips and facts.
• Our Healthy Kids Club mails youth members a new book, welcome
packet, Kid Club membership card, and quarterly newsletters when
signed up by a parent or guardian.
Healthy Weight
Oklahoma Complete Health provides adult and family memberships
to local YMCAs to members in care management to support physical
activity and healthy lifestyles.
We also offer virtual WeightWatchers memberships for members ages
18 and older in care management whose providers recommend an
increase in healthy eating and physical activity to reduce their BMI.
OklahomaCompleteHealth.com | 1-833-752-1664 (TTY: 711)
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Benefit Description
Housing Insecurity
and Homelessness
Oklahoma Complete Health supports members experiencing housing
insecurity or homelessness by:
• Partnering with organizations that provide shelter for members
experiencing homelessness following discharge from an Oklahoma
City hospital.
• Partnering with Legal Aid Services to provide support to members
in care management who need help with employment, housing,
social service benefits, or health-related legal matters.
Nutrition Support
and Food Security
For members in care management who screen positive for food
insecurity, Oklahoma Complete Health provides up to $100 per year
in Food Rx vouchers for nutritional foods.
For qualified members in care management who are coming home
from a hospital stay, including members with high-risk pregnancies,
we provide seven days of special meals delivered to their homes.
For members in care management who need more nutritional
counseling for a chronic condition, we expand upon the state’s
nutritional counseling benefit by four more hours per year.
Over-the-Counter (OTC) Products
Oklahoma Complete Health provides an OTC benefit to all members
for up to $30 per household per quarter to buy items like cold
medicine, vitamins, pain relievers, first aid care, and more.
Pyx Health (Pyx)
Pyx is a mobile app that reduces social isolation by providing
companionship and resources to adult members who screen positive
for social isolation or who have a health condition that would benefit
from daily contact with Pyx. Members get phone calls from the Pyx
Compassionate Call Center and have daily interaction with Pyx, a friendly
24/7 chatbot that provides an interactive and supportive experience.
Ready for my Recovery
Our Ready for my Recovery benefit supports members on their recovery
journey by providing a $30 My Health Pays
®
reward for every six months
of active participation in recovery treatment, as well as a recovery
backpack that includes a water bottle, self-care kit, journal, pen, and
BH information and resources.
Value-Added Services
7
Benefit Description
Remote Patient Monitoring (RPM)
Our diabetes program uses cellular technology, real-time glucose
readings, and automatic supply refills to help members keep track of
their diabetes. Members will get a supply kit delivered to their home
with an introduction to the program, a glucometer, a how-to guide,
and a supply of testing strips. Our diabetes vendor will monitor the
member’s records and contact them if readings are missed or higher
than normal.
Our high-risk pregnancy diabetes program is a special program
for pregnant members. It helps members keep track of their blood
pressure, their glucose, and their baby’s heartbeat.
Oklahoma Complete Health care managers will help schedule
appointments if needed.
Respite Care
Oklahoma Complete Health will cover the cost of up to 48 hours per
year of respite support for the caregivers of members who are in care
management. More respite care hours can help reduce caregiver burnout.
Sports and Camp Physicals
Oklahoma Complete Health covers sports or camp physicals for youth
members age 5-18. The physical exam checks:
• Height, weight, and blood pressure.
• Vision.
• The heart and lungs.
• Joints and motion.
Start Smart for Your Baby
®
(SSFYB) Additional Benefits
In addition to our evidence-based SSFYB CM program, we offer SSFYB
members several benefits, including:
• Access to community-based doulas in Tulsa through the Tulsa Birth
Equity Initiative and in Oklahoma City through Agape Midwifery
and Wellness;
• Unlimited 24/7 access to virtual doulas.
• Support for members who are breastfeeding for up to 12 months
after delivery through Health in Her HUE and Pacify; Health in
Her HUE connects Black women and women of color to culturally
sensitive health care providers, evidence-based health content,
and Centering Pregnancy community support groups;
• A hospital-grade breast pump to support breastfeeding
(1 per pregnancy);
Value-Added Services
OklahomaCompleteHealth.com | 1-833-752-1664 (TTY: 711)
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Benefit Description
Start Smart for Your Baby
®
(SSFYB) Additional Benefits
• Community baby showers where members can get a portable crib
gift and safe sleep education (1 crib per pregnancy);
• Transportation to appointments for members in care management
with high-risk pregnancies provided by local partners OK PICK
Transportation, MedHaul, SendaRide, and Modivcare: and
• Prenatal education and parenting classes when referred by
Care Manager.
Tobacco Cessation
Helping Oklahomans quit tobacco will reduce the burden of
chronic conditions for members. Oklahoma Complete Health offers
My Health Pays
®
incentives to support members who want to stop
using tobacco. We offer $25 for the first fill of medication to quit
and $50 for completing the program.
Traditional Healing Grants
Oklahoma Complete Health respects Members' cultural preferences for
healthcare by providing a $250 grant for ceremonial or spiritual healing
that may help in improved BH or physical health management.
Vision Services for Adults
Oklahoma Complete Health expands the state’s covered vision services for
members ages 21 and older by offering a routine eye exam every other year.
We also offer these benefits at no cost:
Extra help for complex health conditions through our case
and disease management programs.
Coordination of care with programs and services in
your community.
A 24/7 Nurse Advice Line for advice about any health-related
problems. Call 1-833-752-1664 (TTY: 711) to talk to a nurse live.
These Important Documents are on our Website:
Set Up Your Online Member Portal Account
Value-Added Services
9
These Important Documents are on our Website:
Go to OklahomaCompleteHealth.com to view:
Our Provider Directory: The Oklahoma Complete Health online provider directory
has the most current list of in-network healthcare providers. This list is updated daily.
Use our “Find a Provider” tool to search for a provider in your area.
Your Member Handbook: The Oklahoma Complete Health member handbook can
be found under the “Member” section. It has helpful information about your coverage
and benefits.
To get a printed copy of the provider directory or member handbook, please call Member
Services at 1-833-752-1664 (TTY: 711). We will send you copies of these materials at no cost.
Set Up Your Online Member Portal Account
Getting your healthcare information online is easy. To get started, go to
Member.OklahomaCompleteHealth.com to make an account with EntryKeyID.
If you already have an EntryKeyID login, you can use the same email and password
for the Oklahoma Complete Health member portal.
To make an account, you will need:
An email address.
Your member ID, as found on your membership card.
Your first name, last name, and date of birth.
Follow the instructions on screen to make an ID and password. After you log in, you will have
to enter your member ID and date of birth to link your new EntryKeyID.
Once your account is set up on the Oklahoma Complete Health member portal, you will be
able to see your health data, claims, risk assessments, and more. Your EntryKeyID can also be
used to access your health data from third-party applications that support patient access.
Value-Added Services
OklahomaCompleteHealth.com | 1-833-752-1664 (TTY: 711)
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Know Where to go for Care
Get the Right Care at the Right Place
Make sure you know where to get medical care when you need it. If you get sick or hurt,
you have many options to get the care you need.
PRIMARY CARE PROVIDER (PCP)
Your PCP is your main provider. If your condition isn’t life threatening, calling your PCP
should be your first choice.
Call your PCP if you need:
• Help with colds, the flu, or fever.
• Care for ongoing health issues
like asthma or diabetes.
• An annual wellness exam.
• Vaccines.
• General advice about your
overall health.
NURSE ADVICE LINE
Our Nurse Advice Line is here for you 24 hours a day, seven days a week.
Call 1-833-752-1664 (TTY: 711) to talk to someone who can answer questions about
your health. They can also help you decide where to go for care.
Call the Nurse Advice Line if you need:
• Help knowing if you should go to urgent care or wait to see your PCP.
• Help caring for a sick child.
• Answers to questions about your health.
URGENT CARE CENTER
Urgent care centers help treat illnesses or injuries that aren’t life threatening but can’t wait
until the next day. If your PCP’s office is closed, an urgent care center can give you fast,
hands-on care. Urgent care centers can also offer shorter wait times than the ER.
Go to an in-network urgent care center for:
• Sprains.
• Ear infections.
• High fevers.
• Flu symptoms with vomiting.
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EMERGENCY ROOM (ER)
Anything that could endanger your life (or your unborn child’s life, if you’re pregnant) without
immediate medical attention is considered an emergency situation. Emergency services treat
accidental injuries or the onset of what may be a life-threatening medical condition.
Go to the ER if you have:
• Broken bones.
• Bleeding that won’t stop.
• Labor pains or other bleeding
(if you’re pregnant).
• Severe chest pains or heart attack symptoms.
• Stroke symptoms, such as slurred speech,
facial drooping, or arm numbness.
• Overdosed on drugs.
• Eaten poison.
• Bad burns.
• Convulsions or seizures.
• Trouble breathing.
• The sudden inability to see, move, or speak.
• Gun or knife wounds.
• Self-harm that needs medical attention.
Although some things may seem like an emergency at the time, you should only use the ER if it is
a true emergency.
Avoid the ER and call your PCP, the Nurse Advice Line, or an urgent care center for things like:
• A cold, sore throat, ear ache, or the flu.
• Sprains or strains.
• Cuts or scrapes that don’t need stitches.
• Medicine or prescription refills.
• Diaper rash.
MENTAL HEALTH CRISIS SERVICES
Mental health crisis services help individuals who are having a mental health crisis, which is any
situation in which a person's behavior could put them at risk of hurting themselves or others.
Call or text the Suicide & Crisis Lifeline at 988 if you are having:
• A panic attack.
• Extreme depression or anxiety.
• Drug or alcohol problems.
• Thoughts about suicide.
• Thoughts of wanting to harm yourself
or others.
OklahomaCompleteHealth.com | 1-833-752-1664 (TTY: 711)
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Your Care When You Change Health Plans or Doctors
If you choose to leave Oklahoma Complete Health, we will share your health
information with your new plan. You can finish receiving any services that have
already been authorized by your previous health insurance or SoonerCare, even
if the provider you are seeing is an out-of-network provider. Prior authorizations
will be honored until the services are used or until 90 days after your new plan
benefits begin, whichever comes first. After that, we will help you find a provider
in our network to get any additional services if you need them.
If you are pregnant when you join Oklahoma Complete Health you can continue
the care you were receiving before you joined our plan. You can continue seeing
your doctor even if he or she is an out-of-network provider. If you are receiving
chemotherapy or radiation treatment, dialysis, major organ or tissue transplant
services, bariatric surgery, Synagis treatment, medications for Hepatitis C
treatment or if you are terminally ill, when you change plans you can continue
your current treatment plan.
Children receiving private duty nursing services will continue to receive these
services. These services will only change if we perform a new assessment and
determine your child needs different services.
We will continue to cover your out-of-state services and/or meals and lodging
assistance if it is already being received from SoonerCare when you join our plan.
If you are receiving services for hemophilia, those services will continue being
provided by your current hemophilia providers for up to 90 days even if the
provider is out-of-network. After 90 days, we can help you find a network provider.
If you are on a current treatment plan and receiving behavioral health services,
you may keep seeing your current behavioral health treatment provider(s) for
up to 90 days, even if the provider is out-of-network. After 90 days, we can help
you find a network provider.
13
If you are waiting for durable medical equipment (DME) or supplies authorized and
ordered prior to joining our plan, we will help you to receive these items on time.
If your PCP leaves Oklahoma Complete Health, we will tell you in writing within 15
days from when we know about this. We will tell you how you can choose a new PCP,
or we will choose one for you if you do not make a choice.
If you are on a current treatment plan and getting treatment for a chronic or acute
medical condition, you may continue treatment through the current period or active
treatment, or for up to 90 calendar days, whichever is less. After this period, we can
help you find a network provider.
If you are pregnant and in the second or third trimester, you may continue your
care through the postpartum period which begins immediately after childbirth
and extends for about six weeks. After this period, we can help you find a
network provider.
If you have any questions, call Member Services
at 1-833-752-1664 (TTY: 711)
OklahomaCompleteHealth.com | 1-833-752-1664 (TTY: 711)
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Tell Us About Your Health
Oklahoma Complete Health wants to help you get and
stay healthy. Our My Health Screening helps us stay
updated about your current health needs.
My Health Screening will ask you questions about your current health. Your provider
and health plan will use this information to learn about any health changes you’ve
had or to better meet your health needs. That’s why it’s important to complete this
form every year. With this information, we can meet your specific health needs
with more services or assistance.
COMPLETE THE MY
HEALTH SCREENING FORM
There are several ways to complete the form:
1
See the back of the booklet for the My Health
Screening form. Then, mail it back to us using
the postage paid envelope.
2
Scan the QR code to complete the form online.
3
Go to Member.OklahomaCompleteHealth.com
to complete the form on the member portal.
Scan with your
phone to complete
this form on the
member portal.
Start Earning Rewards
If you are in our care management program, a member
of our care coordination team will call you to complete
the screening over the phone. This form is confidential.
Make sure to complete one form for every Oklahoma
Complete Health member. If you need more
My Health Screening forms, call Member Services at
1-833-752-1664 (TTY: 711) or complete additional forms
online. Go to Member.OklahomaCompleteHealth.com
and login into your member portal.
Remember to complete this screening every year.
As part of our My Health Pays
®
program, you will earn
a $10 reward for completing the form.
15
Start Earning Rewards
It’s easy to earn rewards.
After you complete a healthy activity, we will add the reward
amount directly to your My Health Pays
®
Visa
®
prepaid card*.
If you don’t have a card yet, we will mail you one after you complete your first healthy activity.
You can keep earning My Health Pays
®
rewards by completing more healthy activities.
Your rewards will be added to your card once we are notified.
You can earn rewards for doing things like
annual screenings, tests, and more.
Spend rewards at stores like Walmart or
on necessities like rent, utilities, and child care.**
*This My Health Pays
®
Visa
®
prepaid card is issued by The Bancorp Bank, N.A. Member FDIC, pursuant to a
license from Visa U.S.A. Inc. Card cannot be used everywhere Visa debit cards are accepted.
**Rewards cannot be used to buy alcohol, tobacco, or firearm products.
OklahomaCompleteHealth.com | 1-833-752-1664 (TTY: 711)
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Primary Care Provider (PCP)
Your Primary Care Provider (PCP)
is your main personal doctor.
After you choose your PCP, it’s important to make an appointment with them
so you can get to know each other. Building a strong relationship with your PCP
helps you feel comfortable talking about your health.
Your PCP will keep your records and be aware of any changes to your health.
Always call your PCP when you feel sick or have any health questions. If you did
not choose a PCP, one was assigned to you. You can change your PCP any time
through our secure online member portal. You can also call us.
FIND A PCP
Go to Member.OklahomaCompleteHealth.com to choose or change your PCP.
-or-
Call us at 1-833-752-1664 (TTY: 711).
AFTER YOU CHOOSE YOUR PCP, CALL TO SET UP YOUR APPOINTMENT.
A yearly checkup with your PCP is the best way
for you to stay informed about your health.
Talk with your provider about any changes you’ve
noticed or concerns you may have. Your PCP may
recommend tests or other preventive care services
to help monitor your health. Take this opportunity
to ask any questions you may have.
If you need help scheduling this visit, call us at
1-833-752-1664 (TTY: 711)
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STAY INFORMED ABOUT YOUR CHILD’S HEALTH
Babies and young children need to see their providers regularly, too.
It is important for your child to have an annual health check, even
when they are not sick. The chart below shows when babies, young
children, and teens should see their PCP.
HEALTH CHECK SCHEDULE
Birth
◯ 3 to 5 days
◯ 1 month
◯ 2 months
◯ 3 months
◯ 4 months
◯ 6 months
◯ 9 months
Early Childhood
◯ 12 months
◯ 15 months
◯ 18 months
◯ 24 months
◯ 30 months
◯ 3 years
◯ 4 years
Middle Childhood
& Adolescence
◯ Every year until your
child is age 21
Your child’s health check includes an
exam and vaccines to help prevent
diseases. Talk to your child’s provider
about any health issues or concerns.
Notification of Pregnancy
Take Care of Yourself
and Your Baby
Our Start Smart for Your Baby
®
program provides customized support
and care for pregnant individuals and new parents. This program helps
you focus on your health during your pregnancy and your baby’s first year.
START SMART FOR YOUR BABY OFFERS THESE
BENEFITS AT NO COST TO YOU:
• Information abo
ut pregnancy and newborn care.
• Community help with housing, food, clothing, and cribs.
• Breastfeeding support and resources.
• Medical staff to work with you and your provider if you have
any issues during your pregnancy.
• Text and email health tips for you
and your newborn.
GET STARTED
If you are pregnant, complete our
Notification of Pregnancy (NOP) form
online. You can also find the form in the back
of the booklet. Fill it out and mail it back to
us using the postage-paid envelope in the
back of this booklet. We will follow up to
talk with you about the details of our
Start Smart for Your Baby
®
program.
Earn $25 for completing this within your
first trimester or $10 for completing in
your second trimester.
OklahomaCompleteHealth.com | -
-- (TTY: )
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Statement of Non-Discrimination
Oklahoma Complete Health complies with applicable Federal civil rights laws and does not discriminate
on the basis of race, color, national origin, age, disability, or sex. Oklahoma Complete Health does not
exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
Oklahoma Complete Health:
· Provides aids and services at no cost to people with disabilities to communicate effectively with us,
such as:
– Qualified sign language interpreters
– Written information in other formats (large print, audio, accessible electronic formats, other
formats)
· Provides language services at no cost to people whose primary language is not English, such as:
– Qualified interpreters
– Information written in other languages
If you need these services, contact Oklahoma Complete Health at 1-833-752-1664 (TTY: 711). We’re here
for you Monday-Friday from 8 a.m. to 5 p.m.
If you believe that Oklahoma Complete Health has failed to provide these services or discriminated in
another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance
with Oklahoma Complete Health by mail, phone, fax or email at:
Oklahoma Complete Health
Attn: Grievances Department
P.O. Box 10353
Van Nuys CA, 91410-0353
Phone: 1-833-752-1664 (TTY: 711)
Fax: 1-833-812-0027
Email: OKCompleteHealth_[email protected]
If you need help filing a grievance, Oklahoma Complete Health is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services,
Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services,
200 Independence Avenue SW., Room 509F, HHH Building
Washington, DC 20201
Phone: 1-800-368-1019, 1-800-537-7697 (TDD).
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
CAD_136011M State Approved 10262023 OK4CADINS36011M_0SSP
© 2023 Oklahoma Complete Health. All rights reserved. Caid_SSP-NDN-NOLA-OK-Eng.Spa_230706
Declaración de No Discriminación
Oklahoma Complete Health cumple con las leyes de derechos civiles Federales aplicables y no
discrimina por raza, color, nacionalidad de origen, edad, discapacidad ni sexo. Oklahoma Complete
Health no excluye a personas ni las trata de forma diferente por motivos de raza, color, nacionalidad,
edad, discapacidad o sexo.
Oklahoma Complete Health:
· Brinda asistencia y servicios, sin costo alguno, a las personas con discapacidades para comunicarse
de manera eficaz con nosotros, como los siguientes:
– Intérpretes de lengua de señas calificados
– Información escrita en otros formatos (letra grande, audio, formatos electrónicos accesibles,
otros formatos)
· Brinda servicios de idiomas sin costo para las personas cuyo idioma principal no es el inglés,
como los siguientes:
– Intérpretes calificados
– Información escrita en otros idiomas
Si necesita estos servicios, llame a Oklahoma Complete Health al 1-833-752-1664 (TTY: 711).
Atendemos de lunes a viernes, de 8a.m. a 5p.m.
Si considera que Oklahoma Complete Health no le proporcionó estos servicios o que, de otra manera,
lo discriminó por motivos de raza, color, nacionalidad de origen, edad, discapacidad o sexo, puede
presentar una queja ante Oklahoma Complete Health por correo postal, teléfono, fax o correo electrónico:
Oklahoma Complete Health
Attn: Grievances Department
P.O. Box10353
Van Nuys CA, 91410-0353
Teléfono: 1-833-752-1664 (TTY: 711)
Fax: 1-833-812-0027
Correo electrónico: OKCompleteHealth_[email protected]
Si necesita ayuda para presentar una queja, Oklahoma Complete Health está disponible para ayudarlo.
También puede presentar una queja de derechos civiles a la U.S Department of Health and Human
Services, Office for Civil Rights de manera electrónica mediante el Portal de Reclamos de la Office for
Civil Rights, disponible en https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, o por correo postal o
teléfono mediante la siguiente información:
U.S. Department of Health and Human Services,
200Independence Avenue SW., Room509F, HHH Building
Washington, DC20201
Teléfono: 1-800-368-1019, 1-800-537-7697 (TDD).
Los formularios de reclamo están disponibles en http://www.hhs.gov/ocr/office/file/index.html.
If you, or someone you are helping, have questions about Oklahoma
Complete Health, and are not proficient in English, you have the right
to get help and information in your language at no cost and in a timely
manner. If you, or someone you are helping, have an auditory and/or
visual condition that impedes communication, you have the right to
receive auxiliary aids and services at no cost and in a timely manner.
To receive translation or auxiliary services, please contact Member
Services at 1-833-752-1664 (TTY: 711).
Español
(Spanish)
Si usted, o alguien a quien está ayudando, tiene
preguntas acerca de Oklahoma Complete Health y
no domina el inglés, tiene derecho a obtener ayuda
e información en su idioma sin costo alguno y de
manera oportuna. Si usted, o alguien a quien está
ayudando, tiene un impedimento auditivo o visual que
le dificulta la comunicación, tiene derecho a recibir
ayuda y servicios auxiliares sin costo alguno y de
manera oportuna. Para recibir servicios auxiliares o de
traducción, comuníquese con Servicios para Miembros
al 1-833-752-1664 (TTY: 711).
Tiếng Việt
(Vietnamese)
Nếu quý vị hoặc người mà quý vị đang giúp đỡ có câu
hỏi về Oklahoma Complete Health và không thành
thạo tiếng Anh, quý vị có quyền được trợ giúp và
nhận thông tin bằng ngôn ngữ của mình miễn phí và
kịp thời. Nếu quý vị hoặc người mà quý vị đang giúp
đỡ mắc bệnh về thính giác và/hoặc thị giác gây cản
trở giao tiếp, quý vị có quyền được nhận các hỗ trợ
và dịch vụ phụ trợ miễn phí và kịp thời. Để nhận dịch
vụ thông dịch hoặc dịch vụ phụ trợ, vui lòng liên hệ
bộ phận Dịch Vụ Thành Viên theo số 1-833-752-1664
(TTY: 711).
中文
(Chinese)
如果您，或是您正在協助的對象，有關於
Oklahoma Complete Health 方面的問題，且不精通
英語，您有權利免費並及時以您的母語獲幫助和
訊息。如果您，或您正在協助的對象有聽力和/或
視力上的問題，阻礙了溝通，您有權利免費並及
時獲得輔助支援與服務。若要取得翻譯或輔助服
務，請聯絡會員服務部，電話是 1-833-752-1664
（TTY：711）。
한국어
(Korean)
귀하 또는 귀하의 도움을 받는 분이 Oklahoma
Complete Health에 대한 질문이 있는 경우 영어에
능숙하지 않으시면 해당 언어로 시의적절하게
무료 지원과 정보를 받을 권리가 있습니다.
귀하 또는 귀하의 도움을 받는 분이 청각 및/
또는 시각적으로 의사소통에 장애가 있는 경우
시의적절하게 무료 보조 도구 및 서비스를 받을
권리가 있습니다. 번역 또는 보조 서비스를
받으시려면 1-833-752-1664(TTY: 711)번으로
가입자 서비스부에 연락해주십시오.
Deutsch
(German)
Falls Sie oder jemand, dem Sie helfen, Fragen zu
Oklahoma Complete Health hat und nicht Englisch
spricht, haben Sie das Recht, kostenlos und zeitnah
Hilfe und Informationen in Ihrer Sprache zu erhalten.
Falls Sie oder jemand, dem Sie helfen, eine Hör- und/
oder Sehbeeinträchtigung hat, die die Kommunikation
beeinflusst, haben Sie das Recht, kostenlos und zeitnah
zusätzliche Hilfe und Dienstleistungen zu erhalten. Um
eine Übersetzung oder zusätzliche Dienstleistungen zu
erhalten, wenden Sie sich an den Kundendienst unter
1-833-752-1664 (TTY: 711).
ةيبرعلا
(Arabic)
Oklahoma
Complete Health
. (711 :TTY) 1-833-752-1664
မြန်မာဘာသာ
(Burmese)
Oklahoma Complete Health
1-833-752-1664 (TTY: 711)
Lus Hmoob
(Hmong)
Yog tias koj, los sis ib tug neeg twg uas koj tab tom
muab kev pab, muaj cov lus nug hais txog Oklahoma
Complete Health, thiab tsis paub lus Askiv zoo heev, koj
muaj cai tau txais kev pab thiab tej ntaub ntawv qhia
paub ua koj hom lus yam tsis tau them dab tsi li thiab
kom tau raws sij hawm. Yog tias koj, los sis ib tug neeg
twg uas koj tab tom pab, muaj tsos mob txog kev hnov
lus thiab/los sis kev pom kev uas cuam tshuam txog
kev sib txuas lus, koj muaj cai kom tau txais cov kev pab
thiab cov kev pab cuam ntxiv yam tsis tau them dab tsi
li thiab kom tau raws sij hawm. Txhawm rau kom tau
txais cov kev pab cuam txhais ntawv los sis kev pab
ntxiv, thov tiv tauj Member Services (Cov Chaw Muab
Kev Pab Cuam Tswv Cuab) tau ntawm 1-833-752-1664
(TTY: 711).
Tagalog
(Tagalog)
Kung ikaw, o ang iyong tinutulungan, ay may mga
katanungan tungkol sa Oklahoma Complete Health,
at hindi ka mahusay sa Ingles, may karapatan ka na
makakuha ng tulong at impormasyon sa iyong wika
nang walang gastos at sa maagap na paraan. Kung ikaw,
o ang iyong tinutulungan, ay may kondisyon sa pandinig
at/o paningin na nakakaapekto sa komunikasyon, may
karapatan kang makatanggap ng mga karagdagang
tulong at serbisyo nang walang gastos at sa maagap
na paraan. Para makatanggap ng mga serbisyo sa
pagsasalin o mga karagdagang serbisyo, mangyaring
makipag-ugnayan sa Mga Serbisyo para sa Miyembro sa
1-833-752-1664 (TTY: 711).
Français
(French)
Si vous-même ou une personne que vous aidez avez des
questions à propos d'Oklahoma Complete Health et que
vous ne maîtrisez pas l'anglais, vous pouvez bénéficier
gratuitement et en temps utile d'aide et d'informations
dans votre langue. Si vous-même ou une personne
que vous aidez souffrez d'un trouble auditif ou visuel
qui entrave la communication, vous pouvez bénéficier
gratuitement et en temps utile d'aides et de services
auxiliaires. Pour profiter de services de traduction ou
de services auxiliaires, veuillez contacter Services aux
membres au 1-833-752-1664 (TTY: 711).
ລາວລາວ
(Laotian)
ຖ້າຫາກທ່ານ ຫຼື ຜູ້ໃດຜູ້ໜຶ່ງທີ່ທ່ານກຳລັງໃຫ້ການ
ຊ່ວຍເຫຼືອ, ມີຄຳຖາມກ່ຽວກັບ Oklahoma Complete
Health, ແລະ ບໍ່ຊ່ຽວຊານພາສາອັງກິດ, ທ່ານມີສິດ
ໄດ້ຮັບການຊ່ວຍເຫຼືອ ແລະ ຂໍ້ມູນທີ່ເປັນພາສາຂອງທ່ານ
ໂດຍບໍ່ມີຄ່າໃຊ້ຈ່າຍ ແລະ ທັນເວລາ. ຖ້າຫາກທ່ານ ຫຼື
ຜູ້ໃດຜູ້ໜຶ່ງທີ່ທ່ານກຳລັງໃຫ້ການຊ່ວຍເຫຼືອ, ມີສະພາບ
ທາງການໄດ້ຍິນ ແລະ/ຫຼື ການເບິ່ງເຫັນທີ່ຂັດຂວາງ
ການສື່ສານ, ທ່ານມີສິດໄດ້ຮັບການຊ່ວຍເຫຼືອ ແລະ ການ
ບໍລິການເສີມໂດຍບໍ່ມີຄ່າໃຊ້ຈ່າຍ ແລະ ທັນເວລາ. ເພື່ອໃຫ້
ໄດ້ຮັບການບໍລິການແປພາສາ ຫຼື ບໍລິການເສີມ, ກະລຸນາ
ຕິດຕໍ່ຫາ Member Services (ການບໍລິການສະມາຊິກ) ໄດ້ທີ່
1-833-752-1664 (TTY: 711).
ไทย
(Thai)
หากคุณหรือคนที่คุณกำาลังให้ความช่วยเหลือมีคำาถาม
เกี่ยวกับ Oklahoma Complete Health และไม่ชำานาญ
ในการใช้ภาษาอังกฤษ คุณมีสิทธิ์ที่จะขอรับความช่วย
เหลือและข้อมูลในภาษาของคุณโดยไม่เสียค่าใช้จ่าย
อย่างทันท่วงที หากคุณหรือคนที่คุณกำาลังให้ความ
ช่วยเหลือมีภาวะด้านการฟังและ/หรือการมองเห็นที่
เป็นอุปสรรคต่อการสื่อสาร คุณมีสิทธิ์ที่จะขอรับความ
ช่วยเหลือและบริการเสริมโดยไม่เสียค่าใช้จ่ายอย่าง
ทันท่วงที หากต้องการบริการด้านการแปลหรือบริการ
เสริม โปรดติดต่อ บริการสำาหรับสมาชิก ที่หมายเลข
1-833-752-1664 (TTY: 711)
(Urdu)
Oklahoma
Complete Health
(TTY: 711) 1-833-752-1664
ᏣᎳᎩ
(Cherokee)
ᎬᏗ ᏂᎨᎢ ᎢᎯᏍᏉ, ᎠᎴ ᎩᎶᎢ ᎯᎠ ᎦᎵᏔᏅᏔᏅ
ᎠᏍᏕᎵᎭ, ᎤᏙᏓᏆᎠ ᎤᏚᏓᎳ ᎤᎵᏗᏨ ᎠᏓᏅᏖᎭ_ᏕᎪᎠ,
ᎠᎴ ᎦᎶᏔᏅᎥᏍᎦ ᎨᏍᏗ ᎠᏏᎾᎭ Oklahoma Complete
Health, ᎢᎯᏍᏉ ᎤᏙᏓᏆᎠ ᏃᎴ ᎠᏘᏍᎩ ᏰᎵᏉ ᎠᎩᎠ
ᎠᏍᏕᎵᎭ ᎠᎴ ᎦᏁᏫᏗᎭ ᎬᏗ ᎢᎯᏍᏉ ᎢᎬᏁᎢᏍᏗ ᎰᏫᏂᏣ
ᎭᏗ ᏧᎬᏩᎶᏗ ᎠᎴ ᎬᏗ a ᎢᏳᏩᏂᎸᎯ ᎠᎬᏱᏗᏣ. ᎬᏗ ᏂᎨᎢ
ᎢᎯᏍᏉ, ᎠᎴ ᎩᎶᎢ ᎯᎠ ᎦᎵᏔᏅᏔᏅ ᎠᏍᏕᎵᎭ, ᎤᏙᏓᏆᎠ
ᏃᎴ ᎠᎦᏛᎲᏍᎦ ᎠᎴ/ᎠᎴ ᏗᏥᎶᏍᏓᏅᎯ ᎱᏳᎩ ᏍᎩ
ᎠᏔᏲᎯᎭ ᎤᏗᎴᎬᎢ, ᎢᎯᏍᏉ ᎤᏙᏓᏆᎠ ᏃᎴ ᎠᏘᏍᎩ ᏰᎵᏉ
ᏓᏓᏂᎸᎦ ᎠᏎᎯᎭ ᎠᏍᏕᎵᎭ ᎠᎴ ᎤᏙᎳᏂ ᎰᏫᏂᏣ ᎭᏗ
ᏧᎬᏩᎶᏗ ᎠᎴ ᎬᏗ a ᎢᏳᏩᏂᎸᎯ ᎠᎬᏱᏗᏣ. ᏰᎵᏉ ᏓᏓᏂᎸᎦ
ᎠᏁᏍᏗᎭ ᎠᎴ ᎠᏎᎯᎭ ᎤᏙᎳᏂ, ᎠᏔᏲᎯᎭ ᎠᏒᏂᎭ ᏴᏫ
ᎤᏙᎳᏂ ᎰᏫᏂᏣ 1-833-752-1664 (TTY: 711).
(Persian)
Oklahoma Complete Health
( TTY: 711) 1-833-752-1664
Oklahoma Complete Health
Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
Effective 5/5/2023
For help to translate or understand this, please call 1-833-752-1664.
Hearing impaired (TTY: 711).
Para obtener ayuda para traducir o entender esta notificación, llame al 1-833-752-1664.
Personas con Discapacidad Auditiva (TTY: 711).
Covered Entity’s Duties:
Oklahoma Complete Health is a Covered Entity as defined and regulated under the Health
Insurance Portability and Accountability Act of 1996 (HIPAA). Oklahoma Complete Health is
required by law to maintain the privacy of your protected health information (PHI), provide you
with this Notice of our legal duties and privacy practices related to your PHI, abide by the terms of
the Notice that is currently in affect, and notify you in the event of a breach of your unsecured PHI.
This Notice describes how we may use and disclose your PHI. It also describes your rights
to access, amend and manage your PHI and how to exercise those rights. All other uses
and disclosures of your PHI not described in this Notice will be made only with your written
authorization.
Oklahoma Complete Health reserves the right to change this Notice. We reserve the right to
make the revised or changed Notice effective for your PHI we already have as well as any of your
PHI we receive in the future. Oklahoma Complete Health will promptly revise and distribute this
Notice whenever there is a material change to the following:
• The Uses or Disclosures
• Your rights
• Our legal duties
• Other privacy practices stated in the notice
We will make any revised Notices available on our website or through a separate mailing.
CAD_136009E State Approved 09272023
© 2023 Oklahoma Complete Health. All rights reserved.
OK4CADINS36009E_0SSP
Caid_SSP-NOPP-OK-Eng_230719
Internal Protections of Oral, Written and Electronic PHI:
Oklahoma Complete Health protects your PHI. We have privacy and security processes to help.
These are some of the ways we protect your PHI:
• We train our staff to follow our privacy and security processes.
• We require our business associates to follow privacy and security processes.
• We keep our offices secure.
• We talk about your PHI only for a business reason with people who need to know.
• We keep your PHI secure when we send it or store it electronically.
• We use technology to keep the wrong people from accessing your PHI.
Permissible Uses and Disclosures of Your PHI:
The following is a list of how we may use or disclose your PHI without your permission or authorization:
• Treatment - We may use or disclose your PHI to a physician or other health care provider
providing treatment to you, to coordinate your treatment among providers, or to assist us
in making prior authorization decisions related to your benefits.
• Payment - We may use and disclose your PHI to make benefit payments for the health care
services provided to you. We may disclose your PHI to another health plan, to a health care
provider, or other entity subject to the federal Privacy Rules for their payment purposes.
Payment activities may include processing claims, determining eligibility or coverage for
claims, and reviewing services for medical necessity.
• Health Care Operations - We may use and disclose your PHI to perform our healthcare
operations. These activities may include providing customer service, responding to
complaints and appeals, and providing care management and care coordination.
In our healthcare operations, we may disclose PHI to business associates. We will have
written agreements to protect the privacy of your PHI with these associates. We may disclose
your PHI to another entity that is subject to the federal Privacy Rules. The entity must also
have a relationship with you for its healthcare operations. This includes the following:
- Quality assessment and improvement activities
- Reviewing the competence or qualifications of healthcare professionals
- Care management and care coordination
- Detecting or preventing healthcare fraud and abuse
• Group Health Plan/Plan Sponsor Disclosures - We may disclose your protected health
information to a sponsor of the group health plan, such as an employer or other entity that
is providing a health care program to you, if the sponsor has agreed to certain restrictions
on how it will use or disclose the protected health information (such as agreeing not to use
the protected health information for employment-related actions or decisions).
Page 2
Other Permitted or Required Disclosures of Your PHI:
• Fundraising Activities – We may use or disclose your PHI for fundraising activities, such
as raising money for a charitable foundation or similar entity to help finance their activities.
If we do contact you for fundraising activities, we will give you the opportunity to opt-out,
or stop, receiving such communications in the future.
• Underwriting Purposes – We may use or disclose your PHI for underwriting purposes,
such as to make a determination about a coverage application or request. If we do use or
disclose your PHI for underwriting purposes, we are prohibited from using or disclosing
your PHI that is genetic information in the underwriting process.
• Appointment Reminders/Treatment Alternatives - We may use and disclose your PHI
to remind you of an appointment for treatment and medical care with us or to provide you
with information regarding treatment alternatives or other health-related benefits and
services, such as information on how to stop smoking or lose weight.
• As Required by Law - If federal, state, and/or local law requires a use or disclosure of your
PHI, we may use or disclose your PHI information to the extent that the use or disclosure
complies with such law and is limited to the requirements of such law. If two or more laws
or regulations governing the same use or disclosure conflict, we will comply with the more
restrictive laws or regulations.
• Public Health Activities - We may disclose your PHI to a public health authority for the
purpose of preventing or controlling disease, injury, or disability. We may disclose your PHI
to the Food and Drug Administration (FDA) to ensure the quality, safety or effectiveness of
products or services under the jurisdiction of the FDA.
• Victims of Abuse and Neglect - We may disclose your PHI to a local, state, or federal
government authority, including social services or a protective services agency authorized
by law to receive such reports if we have a reasonable belief of abuse, neglect or domestic
violence.
• Judicial and Administrative Proceedings - We may disclose your PHI in response to an
administrative or court order. We may also be required to disclose your PHI to respond to a
subpoena, discovery request, or other similar requests.
• Law Enforcement - We may disclose your relevant PHI to law enforcement when required
to do so for the purposes of responding to a crime.
•
Coroners, Medical Examiners and Funeral Directors - We may disclose your PHI to a coroner
or medical examiner. This may be necessary, for example, to determine a cause of death. We
may also disclose your PHI to funeral directors, as necessary, to carry out their duties.
• Organ, Eye and Tissue Donation – We may disclose your PHI to organ procurement
organizations. We may also disclose your PHI to those who work in procurement, banking
or transplantation of cadaveric organs, eyes, and tissues.
• Threats to Health and Safety - We may use or disclose your PHI if we believe, in good
faith, that the use or disclosure is necessary to prevent or lessen a serious or imminent
threat to the health or safety of a person or the public.
Page 3
• Specialized Government Functions - If you are a member of U.S. Armed Forces, we may
disclose your PHI as required by military command authorities. We may also disclose your
PHI to authorized federal officials for national security concerns, intelligence activities, The
Department of State for medical suitability determinations, the protection of the President,
and other authorized persons as may be required by law.
• Workers’ Compensation - We may disclose your PHI to comply with laws relating to
workers’ compensation or other similar programs, established by law, that provide benefits
for work-related injuries or illness without regard to fault.
• Emergency Situations – We may disclose your PHI in an emergency situation, or if you
are incapacitated or not present, to a family member, close personal friend, authorized
disaster relief agency, or any other person previously identified by you. We will use
professional judgment and experience to determine if the disclosure is in your best
interest. If the disclosure is in your best interest, we will only disclose the PHI that is
directly relevant to the person’s involvement in your care.
• Inmates - If you are an inmate of a correctional institution or under the custody of a
law enforcement official, we may release your PHI to the correctional institution or law
enforcement official, where such information is necessary for the institution to provide you
with health care; to protect your health or safety; or the health or safety of others; or for
the safety and security of the correctional institution.
• Research - Under certain circumstances, we may disclose your PHI to researchers when
their clinical research study has been approved and where certain safeguards are in place
to ensure the privacy and protection of your PHI.
Uses and Disclosures of Your PHI That Require Your Written
Authorization:
We are required to obtain your written authorization to use or disclose your PHI, with limited
exceptions, for the following reasons:
• Sale of PHI – We will request your written authorization before we make any disclosure
that is deemed a sale of your PHI, meaning that we are receiving compensation for
disclosing the PHI in this manner.
• Marketing – We will request your written authorization to use or disclose your PHI for
marketing purposes with limited exceptions, such as when we have face-to-face marketing
communications with you or when we provide promotional gifts of nominal value.
• Psychotherapy Notes – We will request your written authorization to use or disclose any
of your psychotherapy notes that we may have on file with limited exception, such as for
certain treatment, payment or healthcare operation functions.
You have the right to revoke your authorization, in writing at any time except to the extent that
we have already used or disclosed your PHI based on that initial authorization.
Page 4
Individuals Rights:
The following are your rights concerning your PHI. If you would like to use any of the following
rights, please contact us using the information at the end of this Notice.
• Right to Request Restrictions - You have the right to request restrictions on the use and
disclosure of your PHI for treatment, payment, or healthcare operations, as well as disclosures
to persons involved in your care or payment of your care, such as family members or close
friends. Your request should state the restrictions you are requesting and state to whom the
restrictions apply. We are not required to agree to this request. If we agree, we will comply
with your restriction request unless the information is needed to provide you with emergency
treatment. However, we will restrict the use or disclosure of PHI for payment or health care
operations to a health plan when you have paid for the service or item out of pocket in full.
•
Right to Request Confidential Communications - You have the right to request that we
communicate with you about your PHI by alternative means or to alternative locations. This
right only applies if the information could endanger you if it is not communicated by the
alternative means or to the alternative location you want. You do not have to explain the
reason for your request, but you must state that the information could endanger you if the
communication means or location is not changed. We must accommodate your request if it is
reasonable and specifies the alternative means or location where you PHI should be delivered.
• Right to Access and Receive a Copy of your PHI - You have the right, with limited
exceptions, to look at or get copies of your PHI contained in a designated record set. You
may request that we provide copies in a format other than photocopies. We will use
the format you request unless we cannot practicably do so. You must make a request in
writing to obtain access to your PHI. If we deny your request, we will provide you a written
explanation and will tell you if the reasons for the denial can be reviewed. We will also tell
you how to ask for such a review or if the denial cannot be reviewed.
• Right to Amend your PHI - You have the right to request that we amend, or change, your PHI if
you believe it contains incorrect information. Your request must be in writing, and it must explain
why the information should be amended. We may deny your request for certain reasons, for
example if we did not create the information you want amended and the creator of the PHI is able
to perform the amendment. If we deny your request, we will provide you a written explanation.
You may respond with a statement that you disagree with our decision and we will attach your
statement to the PHI you request that we amend. If we accept your request to amend the
information, we will make reasonable efforts to inform others, including people you name, of the
amendment and to include the changes in any future disclosures of that information.
• Right to Receive an Accounting of Disclosures - You have the right to receive a list of
instances within the last 6-year period in which we or our business associates disclosed
your PHI. This does not apply to disclosure for purposes of treatment, payment, health
care operations, or disclosures you authorized and certain other activities. If you request
this accounting more than once in a 12-month period, we may charge you a reasonable,
cost-based fee for responding to these additional requests. We will provide you with more
information on our fees at the time of your request.
Page 5
• Right to File a Complaint - If you feel your privacy rights have been violated or that we
have violated our own privacy practices, you can file a complaint with us in writing or by
phone using the contact information at the end of this Notice.
You can also file a complaint with the Secretary of the U.S. Department of Health and
Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue,
S.W., Washington, D.C. 20201 or calling 1-800-368-1019, (TTY: 1-800-537-7697) or
visiting https://www.hhs.gov/guidance/document/filing-complaint-0.
WE WILL NOT TAKE ANY ACTION AGAINST YOU FOR FILING A COMPLAINT.
• Right to Receive a Copy of this Notice - You may request a copy of our Notice at any time
by using the contact information listed at the end of the Notice. If you receive this Notice
on our web site or by electronic mail (e-mail), you are also entitled to request a paper copy
of the Notice.
Contact Information
Questions about this Notice: If you have any questions about this notice, our privacy practices
related to your PHI or how to exercise your rights you can contact us in writing or by email using
the contact information listed below.
Oklahoma Complete Health
Attn: Privacy Official - Darnell Burgess
14000 Quail Springs Pkwy, Suite 650
Oklahoma City, OK 73134
Page 6
Oklahoma Complete Health – My Health Screening
This My Health Screening form includes demographic (member) information for verification purposes only.
This is completed following all care management procedures. This information is requested in compliance
with applicable federal, HIPAA, contract specific requirements, and Oklahoma state laws.
Member Information (Demographics)
1
Member Name: __________________________________________________________
2
Preferred Phone Number: ______________________________________________
3
Preferred Mailing Address: _____________________________________________
4
Email Address: __________________________________________________________
5
Race:
American Indian/Alaskan Native
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
White
Other (If answer is other, please go to
question 6)
I prefer not to answer.
Unknown
6
Please list other race: __________________________________________________________________
7
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Other (if answer is other, please go to question 8)
I prefer not to answer.
Unknown
8
Please list other ethnicity: _____________________________________________________________
9
What language do you prefer to speak?
English
Spanish
Chinese
Mandarin
Vietnamese
Korean
Other (if answer is other, please go to question 10)
No response
10
Please list other language: _____________________________________________________________
OklahomaCompleteHealth.com
CAD_136005E State Approved 11142023
©2023 Oklahoma Complete Health. All rights reserved.
OK4CADFRM36005E_0SSP
Caid_SSP-HRS-OK-Eng-R_231030
Scan with your phone to
complete this form on
the member portal
Physical Health
11
Do you have any past physical health conditions or surgeries? If so, please explain.
_____________________________________________________________________________________________________
12
In general, how would you rate your health?
Excellent
Very Good
Good
Fair
Poor (If answer is poor, go to question 13)
Unknown
13
Please explain reason for poor health rating. _________________________________________________________
14
Do you have a doctor or health care provider?
Yes (If yes, go to question 15)
No Unknown
15
What is your doctor or health care provider’s name? ______________________________________________
* It is important to identify a doctor or health care provider to help you stay healthy
and in case you get sick.
16
Have you seen your doctor or health care provider in the last 12 months?
Yes (If yes, go to question 17) No Unknown
17
What did you see your doctor for in the past 12 months?
Preventative Care/Wellness Visit
Sick care visit
Post hospital visit
Post Emergency Room visit
Other visit (If other visit, go to question 18)
18
What was the other visit for? _______________________________________________________________________
*Regular wellness exams can help make sure you stay as healthy as you can.
19
How many times have you been in the hospital in the last 3 months?
None
One time
Two times
Three or more times
Unknown
20
How many times have you been in the Emergency Department in the last 3 months?
None
One time
Two times
Three or more times
Unknown
21
Have you ever been told by a doctor or health care provider that you have any of these conditions?
(check all that apply)
Arthritis (If yes, go to question 22)
Asthma
Cancer
Chronic Kidney Disease
COPD/Emphysema
Diabetes, Type 1
Diabetes, Type 2
Pre Diabetes
Heart Disease
Hepatitis
High Blood Pressure
High Cholesterol
HIV
Learning Disability
Sickle Cell Disease
(not trait)
Stroke
_____________________________________________ Member Name:
Member ID: _________________________________________________ ________________________ Member DOB:
22
Wha
t type of arthritis?
Osteoarthritis Rheumatoid arthritis Unknown
23
Have you ever had a transplant?
Yes No
If ye
s, how long ago?
__________________________________________
More than 1 year ago
In the last 12 months
On the transplant list
Unknown
24
Do you have any other conditions not listed above?
25
Do you use any assistive devices such as a cane, walker, wheelchair, scooter/power wheelchair,
hospital bed, Hoyer lift, or oxygen?
Yes, details:
______________________________________________________________________________
______________________________________________________________________________
No Unknown No Response
26
Do you currently receive any services in your home such as Home Health, Homemaking,
Home-Delivered meals, Hospice, or Personal Care in or out of state?
Yes, details:
No Unknown No R
esponse
27
Are you actively receiving treatment for a physical health disorder, including services from
an out of state provider?
Yes (If yes, please go to question 28) No (If no, please go to question 29)
Unknown
28
Please provide details of current treatment for your physical health disorder(s) including the
name and location of the provider.
______________________________________________________________________________________________________
29
Would you like help getting treatment for a physical health disorder?
Yes No Unknown
30
Are you aware of any existing authorizations for services or procedures for physical or
behavioral health including those from an out of state provider?
Yes, details:
______________________________________________________________________________
No Unknown No Response
31
Are you pregnant?
Yes (If yes, go to question 32)
No
Unknown
Not applicable
32
Do you currently have an in or out of state OB/GYN? If yes, please provide details of your current
treatment for pregnancy, and the name and location of the provider.
_____________________________________________________________________________________________________________________
33
When is your due date (month/day/year)? __________________________
Medications
34
How many medicines are you currently taking that were prescribed by your doctor
or health care provider?
0 Prescriptions
1-3 Prescriptions (If 1-3, answer questions 35-37)
4-7 Prescriptions (If 4-7, answer questions 35-37)
Greater than or equal to 8 Prescriptions (If 8+, answer questions 35-37)
Unknown
35
Does anything prevent you from taking your medicines the way your doctor or health care provider
wants you to?
Yes (If yes, please go to question 36) No Unknown
36
What prevents you from taking your medicine? ______________________________________________
37
Do you ever forget to take your medicines?
Yes No Sometimes Unknown
Behavioral Health
38
Do you have any past Behavioral Health conditions? If so, please explain.
_____________________________________________________________________________________________________
39
During the past month, have you often been bothered by feeling down, depressed, or hopeless?
Yes No Unknown
40
Are you actively receiving treatment for a behavioral health disorder, including services from
an out of state provider?
Yes (If yes, please go to question 41) No (If no, go to question 42) Unknown
41
Please provide details of current treatment for a behavioral health disorder(s) including the name
and location of the provider.
_____________________________________________________________________________________________________
42
Would you like help getting treatment for a behavioral health disorder?
Yes No Unknown
Social Determinants of Health
1
In the past 2 months, have you been living in stable housing that you own, rent, or stay in as
part of a household?
Yes No Unknown
Member Name: _____________________________________________
Member ID: _________________________________________________ Member DOB: ________________________
2
What is your housing situation today?
I have housing.
I do not have housing (staying with others, in a hotel, shelter, living outside, in a car,
or in a park).
I choose not to answer this question.
3
In the past 12 months has the electric, gas, or water company threatened to shut off services
in your home?
Yes No Already shut off
4
In the past 3 months, how often have you worried that your food would run out before you had money
to buy more?
Never Sometimes Often Very often
5
In the past 12 months, or since the last time we checked in, has lack of reliable transportation kept you
from medical appointments, meetings, work or from getting things needed for daily living?
Yes No Unknown
6
Do you always feel safe in your home and around all the people in your life?
Yes No (If no, go to question 7) Unknown
7
Please explain any safety concerns you have: _________________________________________________
8
Which of the following are you currently receiving help with at this time? (Select all that apply)
: _____________________________________________________________________________________
_________________________________________________________________________________
__________________________________________________________________________
________________________________________________
___________________________________________
___________________________________________________
__________________________________
Food, details
Housing, details:
Transportation, details:
Utilities (heat, electricity, water, etc.), details:
Medical care, medicine, medical supplies, details:
Dental services and Vision services, details:
Applying for public benefits (WIC, SSI, SNAP, etc.), details:
Understanding health information or completing medical forms, details:
________________________________________________________________________________________________________
_______________________________________________
__________________________________________________
More help with activities of daily living, details:
Childcare/other child-related issues, details:
Debt/loan repayment, details:
__________________________________________________________________
_____________________________________________________________________________
____________________________________________________________________________
________________________________________________________
_________________________________________________________________
____________________________________________________________________________________
Legal Issues, details:
Employment, details:
Access to a working telephone, details:
Access to the Internet, details:
Other, details:
I don’t receive help with any of these.
9
Which of the following would you like to receive help with at this time? (Select all that apply)
Food, details: _____________________________________________________________________________________
Housing, details: _________________________________________________________________________________
Transportation, details: __________________________________________________________________________
Utilities (heat, electricity, water, etc.), details: ________________________________________________
Medical care, medicine, medical supplies, details: ___________________________________________
Dental services and Vision services, details: ___________________________________________________
Applying for public benefits (WIC, SSI, SNAP, etc.), details: __________________________________
Understanding health information or completing medical forms, details:
________________________________________________________________________________________________________
More help with activities of daily living, details: _______________________________________________
Childcare/other child-related issues, details: __________________________________________________
Debt/loan repayment, details: __________________________________________________________________
Legal Issues, details: _____________________________________________________________________________
Employment, details: ____________________________________________________________________________
Access to a working telephone, details: ________________________________________________________
Access to the Internet, details: _________________________________________________________________
Other, details: ____________________________________________________________________________________
I don’t want help with any of these.
General Information
Assessment Completed date: ________________________________________________________________________
Assessment Completed by: __________________________________________________________________________
Relationship to Member
Self
Member Representative with permission
Parent/Guardian
Envolve
Health Plan
Vendor (If vendor, go to question 2)
Other (If other, go to question 1)
1
If other relationship to member, please explain: ______________________________________________
2
Name of agency completing assessment: _____________________________________________________
Member Notifica
Member Notifica
tion of Pr
tion of Pr
e
e
gnanc
gnanc
y
y
This form is confidential. If you have any problems or questions, please call Oklahoma Complete Health at
1-833-752-1664 (TTY: 711) and for SoonerSelect Children’s Specialty Program please call 1-833-752-1665 (TTY: 711).
This form is also available online at OklahomaCompleteHealth.com.
*Required Field
*Are You Pregnant?
Yes No * If you are pregnant, please continue to answer all the questions.
Return the form in the envelope provided.
We may call you if we find that you are at risk for problems with your pregnancy.
*Member ID #:
Today’s Date MMDDYYYY:
Your First Name:
Your Last Name:
*Your Birth Date MMDDYYYY:
Mailing Address:
City: State: Zip Code:
Home Phone: Cell Phone:
Would you like to receive text messages about pregnancy and newborn care? Yes No
If you do not have an unlimited texting plan, message and data rates may apply. Text STOP to unsubscribe.
Please note, texting is not secure and may be seen by others.
Email Address:
*Your OB Provider’s Name:
*Your Due Date MMDDYYYY:
Primary insurance (for mom or baby) other than Medicaid? Yes No
Race/Ethnicity (select all that apply): White Black/African American Hispanic/Latina
American Indian/Native American Asian Hawaiian/Pacific Islander
Other If other ethnicity, please specify:
Preferred Language (if other than English):
Pediatrician chosen? Yes No Pediatrician Name:
Number of Full Term Deliveries: Number of Miscarriages:
Number of Preterm Deliveries: Number of Stillbirths:
Planning to breastfeed? Yes No If no, what is the reason?
Rev. 11 02 2023
OK-MNOP-6220
Height (Feet, Inches):
Pre-Pregnancy Weight:
Your Medical History
*Do you have any of the following? Yes No
If yes, mark all that apply.
Previous preterm delivery (<37 weeks or a delivery more than three weeks early)? Yes No
Recent delivery within past 12 months? Yes No Was delivery within past 6 months? Yes No
Previous C-Section? Yes No Diabetes (Prior to Pregnancy)? Yes No
This form is confidential. If you have any problems or questions, please call Sooner Select/Oklahoma Complete Health at 833-752-1664 (TTY: 711)
and for Children’s Specialty Program please call 833-752-1665. This form is also available online at Oklahomacompletehealth.com.
*Required Field
*Are You Pregnant?
Yes No * If you are pregnant, please continue to answer all the questions.
Return the form in the envelope provided.
We may call you if we find that you are at risk for problems with your pregnancy.
*Medicaid ID #:
Today’s Date MMDDYYYY:
Your First Name:
Your Last Name:
*Your Birth Date MMDDYYYY:
Mailing Address:
City: State: Zip Code:
Home Phone: Cell Phone:
Would you like to receive text messages about pregnancy and newborn care? Yes No
If you do not have an unlimited texting plan, message and data rates may apply. Text STOP to unsubscribe.
Please note, texting is not secure and may be seen by others.
Email Address:
*Your OB Provider’s Name:
*Your Due Date MMDDYYYY:
Primary insurance (for mom or baby) other than Medicaid? Yes No
Race/Ethnicity (select all that apply): White Black/African American Hispanic/Latina
American Indian/Native American Asian Hawaiian/Pacific Islander
Other If other ethnicity, please specify:
Preferred Language (if other than English):
Pediatrician chosen? Yes No Pediatrician Name:
Number of Full Term Deliveries: Number of Miscarriages:
Number of Preterm Deliveries: Number of Stillbirths:
Planning to breastfeed? Yes No If no, what is the reason?
© 2021 Oklahoma Complete Health. All rights reserved.
Rev. 08 15 2023
OK-MNOP-6220
Member Notification of Pregnancy
*6220*
Height (Feet, Inches):
Pre-Pregnancy Weight:
Your Medical History
*Do you have any of the following? Yes No
If yes, mark all that apply.
Previous preterm delivery (<37 weeks or a delivery more than three weeks early)? Yes No
Recent delivery within past 12 months? Yes No Was delivery within past 6 months? Yes No
Previous C-Section? Yes No Diabetes (Prior to Pregnancy)? Yes No
CAD_136021E State Approved 09272023
© 2023 Oklahoma Complete Health. All rights reserved.
OK4CADFRM36021E_SSCP
Caid_SSP-CSP-NOP-OK Eng-R_231102
Rev. 11 02 2023
OK-MNOP-6220-2© 2023 Oklahoma Complete Health. All rights reserved.
This form is confidential. If you have any problems or questions, please call Sooner Select/Oklahoma Complete Health at 833-752-1664 (TTY: 711)
and for Children’s Specialty Program please call 833-752-1665. This form is also available online at Oklahomacompletehealth.com.
*Required Field
*Are You Pregnant?
Yes No * If you are pregnant, please continue to answer all the questions.
Return the form in the envelope provided.
We may call you if we find that you are at risk for problems with your pregnancy.
*Medicaid ID #:
Today’s Date MMDDYYYY:
Your First Name:
Your Last Name:
*Your Birth Date MMDDYYYY:
Mailing Address:
City: State: Zip Code:
Home Phone: Cell Phone:
Would you like to receive text messages about pregnancy and newborn care? Yes No
If you do not have an unlimited texting plan, message and data rates may apply. Text STOP to unsubscribe.
Please note, texting is not secure and may be seen by others.
Email Address:
*Your OB Provider’s Name:
*Your Due Date MMDDYYYY:
Primary insurance (for mom or baby) other than Medicaid? Yes No
Race/Ethnicity (select all that apply): White Black/African American Hispanic/Latina
American Indian/Native American Asian Hawaiian/Pacific Islander
Other If other ethnicity, please specify:
Preferred Language (if other than English):
Pediatrician chosen? Yes No Pediatrician Name:
Number of Full Term Deliveries: Number of Miscarriages:
Number of Preterm Deliveries: Number of Stillbirths:
Planning to breastfeed? Yes No If no, what is the reason?
© 2021 Oklahoma Complete Health. All rights reserved.
Rev. 08 15 2023
OK-MNOP-6220
Member Notification of Pregnancy
*6220*
Height (Feet, Inches):
Pre-Pregnancy Weight:
Your Medical History
*Do you have any of the following? Yes No
If yes, mark all that apply.
Previous preterm delivery (<37 weeks or a delivery more than three weeks early)? Yes No
Recent delivery within past 12 months? Yes No Was delivery within past 6 months? Yes No
Previous C-Section? Yes No Diabetes (Prior to Pregnancy)? Yes No
*Member ID #:
Name: Last, First:
Sickle Cell? Ye
s No
Asthma? Ye
s No If yes, are asthma symptoms worse during pregnancy? Yes No
High blood pressure (prior to pregnancy)? Yes No P
revious neonatal death or stillbirth? Yes No
HIV Positive? Yes No HIV Negative? Yes No T
esting refused? Yes No AIDS? Yes No
Thyroid Problems? Yes No If yes, is this a new thyroid problem? Yes No
Seizure Disorder?
Yes No Seizure within the last 6 months? Yes No
Previous alcohol or drug abuse? Yes No
Current Pregnancy History
Preterm labor this pregnancy? Yes No Current gestational diabetes? Yes No
Current twins? Yes No Current triplets? Yes No
Currently having severe morning sickness? Yes No
Current mental health concerns? Yes
No
List:
Current STD? Yes No List:
Current tobacco use? Yes
No
Amount:
If yes, are you interested in quitting?
Yes
No
Current alcohol use? Yes No Amount:
Current street drug use? Yes No
Taking any prescription drugs (other than prenatal vitamins)? Yes No List:
Any hospital stays this pregnancy?
Yes No
If yes, please list hospitalizations during this pregnancy.
Social Issues
Do you have enough food? Yes No Are you enrolled in WIC? Yes
No
Do you have problems getting to your doctor visits? Yes No Do you have reliable phone access? Yes No
Are you homeless or living in a shelter? Yes No
Are you currently experiencing domestic violence or feel unsafe in your home? Yes No
Please list any other social needs you may have:
Please list anything else you would like to tell us about your health:
If your answers indicate you are at an increased risk for complications during this pregnancy, would you consent to
participate in our Start Smart Case Management program to help you and your baby?
Yes No
