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Oklahoma Department of Human Services

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Oklahoma Department of Human Services
Sequoyah Memorial Office Building, 2400 N. Lincoln Blvd. • Oklahoma City, OK 73105
(405) 521-3646 • Fax (405) 521-6684 • Internet: www.okdhs.org
 
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Adult/Child Abuse and Neglect Hotline: 1-800-522-3511

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OKDHS Home > Library > Forms > Forms and Applications for Services
Library: Forms
OKDHS Forms
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316 forms found    Page 1  2  3  4  5  6  7   
View Form No.Results shown in ascending orderLegacy No.Form Name Category
Open Low Income Home Energy Assistance Walk-In Application (.doc, 4 pp, 679 KB)Open Low Income Home Energy Assistance Walk-In Application (.pdf, 4 pp, 238 KB)
08LH002E
LIHEAP-1-BLow Income Home Energy Assistance Walk-In ApplicationApplications  
LIHEAP  
Open Presumptive Eligibility (PE) Budget Sheet (.doc, 4 pp, 693 KB)Open Presumptive Eligibility (PE) Budget Sheet (.pdf, 4 pp, 140 KB)
08MA003E
MA-PE-1Presumptive Eligibility (PE) Budget SheetApplications  
Medical  
Open Notification of Needed Medical Services (.doc, 3 pp, 609 KB)Open Notification of Needed Medical Services (.pdf, 3 pp, 154 KB)
08MA005E
MS-MA-5Notification of Needed Medical ServicesMedical  
Open Assessment of Assets (.doc, 3 pp, 899 KB)Open Assessment of Assets (.pdf, 3 pp, 186 KB)
08MA011E
MA-011Assessment of AssetsMedical  
Open Consent for Release of Information and Appointment of Representative (.doc, 3 pp, 782 KB)Open Consent for Release of Information and Appointment of Representative (.pdf, 3 pp, 171 KB)
08MA013E
N/AConsent for Release of Information and Appointment of RepresentativeMedical  
Open Reporting of Newborn Child of SoonerCare Member (.doc, 2 pp, 715 KB)Open Reporting of Newborn Child of SoonerCare Member (.pdf, 2 pp, 213 KB)
08MA015E
FSS-NB-001Reporting of Newborn Child of SoonerCare MemberMedical  
Open Authorization for Examination and Billing (.doc, 1 pp, 674 KB)Open Authorization for Examination and Billing (.pdf, 1 pp, 153 KB)Open Authorization for Examination and Billing Instructions (.pdf, 1 pp, 20 KB)
08MA016E
ABCDM-016Authorization for Examination and BillingMedical  
Open Notice to Pregnant Women Regarding Presumptive Eligibility (PE) for SoonerCare (Medicaid) (.doc, 2 pp, 657 KB)Open Notice to Pregnant Women Regarding Presumptive Eligibility (PE) for SoonerCare (Medicaid) (.pdf, 2 pp, 130 KB)
08MA020E
MA-PE-2Notice to Pregnant Women Regarding Presumptive Eligibility (PE) for SoonerCare (Medicaid)Medical  
Open Ledger Sheet for Recipients Account (.doc, 1 pp, 737 KB)Open Ledger Sheet for Recipients Account (.pdf, 1 pp, 13 KB)Open Ledger Sheet for Recipients Account Instructions (.pdf, 1 pp, 17 KB)
08MA021E
ABCDM-099Ledger Sheet for Recipient's Account Medical  
Multiple Programs  
Open Medicaid Income Pension Trust (.doc, 5 pp, 475 KB)Open Medicaid Income Pension Trust Instructions (.pdf, 2 pp, 20 KB)
08MA023E
M-11Medicaid Income Pension Trust Medical  
Open Report of Physicians Examination (.doc, 2 pp, 745 KB)Open Report of Physicians Examination (.pdf, 2 pp, 258 KB)Open Report of Physicians Examination Instructions (.pdf, 1 pp, 18 KB)
08MA080E
ABCDM-80Report of Physician's ExaminationMedical  
Open Notification Regarding Patient in a Nursing Facility (NF), Intermediate Care Facility for the Mentally Retarded (ICF/MR), or Hospice (.doc, 3 pp, 790 KB)Open Notification Regarding Patient in a Nursing Facility (NF), Intermediate Care Facility for the Mentally Retarded (ICF/MR), or Hospice (.pdf, 3 pp, 153 KB)
08MA083E
ABCDM-83Notification Regarding Patient in a Nursing Facility (NF), Intermediate Care Facility for the Mentally Retarded (ICF/MR), or HospiceMedical  
Aging  
Open Management of Recipients Funds (.doc, 2 pp, 530 KB)Open Management of Recipients Funds (.pdf, 2 pp, 81 KB)
08MA084E
ABCDM-096Management of Recipient's FundsMedical  
Aging  
Open Accounting - Recipients Personal Funds and Property (.doc, 1 pp, 667 KB)Open Accounting - Recipients Personal Funds and Property (.pdf, 1 pp, 11 KB)Open Accounting - Recipients Personal Funds and Property Instructions (.pdf, 1 pp, 23 KB)
08MA085E
ABCDM-96-AAccounting - Recipient's Personal Funds and Property Aging  
Medical  
Open Request for Benefits (.doc, 5 pp, 731 KB)Open Request for Benefits (.pdf, 5 pp, 339 KB)
08MP001E
PS-1Request for BenefitsApplications  
Multiple Programs  
Open Responsibilities and Signature for Benefits (.doc, 6 pp, 780 KB)Open Responsibilities and Signature for Benefits (.pdf, 6 pp, 157 KB)
08MP003E
FSS-1-BResponsibilities and Signature for BenefitsMultiple Programs  
Open Benefit Review Report (.doc, 7 pp, 1.1 MB)Open Benefit Review Report (.pdf, 7 pp, 378 KB)
08MP004E
FSS-BR-001Benefit Review ReportMultiple Programs  
Open Information for Benefit Review Reporters (.doc, 2 pp, 726 KB)Open Information for Benefit Review Reporters (.pdf, 2 pp, 57 KB)
08MP006E
N/AInformation for Benefit Review ReportersMultiple Programs  
Open Physician Assessment for TEFRA (.doc, 6 pp, 796 KB)Open Physician Assessment for TEFRA (.pdf, 6 pp, 410 KB)
08OA001E
TEFRA-001Physician Assessment for TEFRAMedical  
Open Request for Citizenship Verification (.doc, 1 pp, 1 MB)Open Request for Citizenship Verification (.pdf, 1 pp, 136 KB)
08OA005E
N/ARequest for Citizenship VerificationMedical  
Open Identity Affidavit (.doc, 1 pp, 189 KB)Open Identity Affidavit (.pdf, 1 pp, 132 KB)
08OA006E
N/AIdentity AffidavitMedical  
Open Important Notice About the Effect of Lump Sum Payments on TANF Benefits (.doc, 4 pp, 77 KB)Open Important Notice About the Effect of Lump Sum Payments on TANF Benefits (.pdf, 4 pp, 123 KB)
08TA006E
FSS-C-4Important Notice About the Effect of Lump Sum Payments on TANF BenefitsTANF  
Open Cooperation Agreement and Request for Good Cause (.doc, 3 pp, 580 KB)Open Cooperation Agreement and Request for Good Cause (.pdf, 3 pp, 149 KB)Open Cooperation Agreement and Request for Good Cause Instructions (.pdf, 1 pp, 15 KB)
08TA012E
C-9Cooperation Agreement and Request for Good CauseChild Support  
Open Time and Progress Report (.doc, 4 pp, 1.1 MB)Open Time and Progress Report (.pdf, 4 pp, 244 KB)
08TW013E
TW-13Time and Progress ReportTANF Work  
TANF  
Open Confidential Intake Form (.doc, 6 pp, 818 KB)Open Confidential Intake Form (.pdf, 6 pp, 376 KB)
09AI002E
ACIS-2Confidential Intake FormApplications  
Field Operations  
Open Request for Approval of Leave (.doc, 2 pp, 693 KB)Open Request for Approval of Leave (.pdf, 2 pp, 193 KB)Open Request for Approval of Leave Instructions (.pdf, 3 pp, 25 KB)
10AD001E
ADM-1Request for Approval of LeaveFinance  
Personnel  
Open Claim Form (.doc, 2 pp, 722 MB)Open Claim Form (.pdf, 2 pp, 199 KB)Open Driver License and Liability Insurance Attestation Instructions (.pdf, 1 pp, 48 KB)
10AD012E
N/ADriver License and Liability Insurance Attestation Contracts and Purchasing  
Risk Management  
Open Child Care Claim (.doc, 2 pp, 982 KB)Open Child Care Claim (.pdf, 2 pp, 182 KB)
10AD121E
ADM-12-SChild Care ClaimChild Care  
Finance  
Open Automatic Deposit Transmittal (.doc, 2 pp, 880 KB)Open Automatic Deposit Transmittal (.pdf, 2 pp, 138 KB)
10OA073E
OPM-73Automatic Deposit TransmittalFinance  
Personnel  
Open Employee Satisfaction Survey (.pdf, 2 pp, 29 KB)
11PE002E
EAP-001Employee Satisfaction SurveyPersonnel  
Open Total Compensation Estimator for 2009 (.xls, 30 KB)
11PE003E
N/ATotal Compensation Estimator for 2009Personnel  
Open Application for Employment (.doc, 4 pp, 823 KB)Open Application for Employment (.pdf, 4 pp, 195 KB)Open Application Data Sheet Instructions (.pdf, 1 pp, 25 KB)
11PE012E
P-12Application for EmploymentApplications  
Personnel  
Open Reasonable Suspicion Checklist (.doc, 2 pp, 183 KB)Open Reasonable Suspicion Checklist (.pdf, 2 pp, 193 KB)
11PE094E
P-94Reasonable Suspicion ChecklistPersonnel  
Open Application Supplement (.doc, 2 pp, 903 KB)Open Application Supplement (.pdf, 2 pp, 224 KB)Open Application Supplement Instructions (.pdf, 1 pp, 13 KB)
11PE201E
P-1-DApplication SupplementApplications  
Open Driver License and Liability Insurance Attestation (.doc, 1 pp, 723 KB)Open Driver License and Liability Insurance Attestation (.pdf, 1 pp, 118 KB)
11RS100E
N/ADriver License and Liability Insurance AttestationRisk Management  
Open Request for a Fair Hearing (.doc, 2 pp, 674 KB)Open Request for a Fair Hearing (.pdf, 2 pp, 153 KB)Open Request for a Fair Hearing Instructions (.pdf, 1 pp, 18 KB)
13MP001E
H-001Request for a Fair HearingApplications  
Legal  
Multiple Programs  
Open Request for Review of Decision on Appeal by the Director of Department of Human Services (.doc, 1 pp, 848 KB)Open Request for Review of Decision on Appeal by the Director of Department of Human Services (.pdf, 1 pp, 127 KB)Open Request for Review of Decision on Appeal by the Director of Department of Human Services Instructions (.pdf, 1 pp, 18 KB)
13MP003E
H-2Request for Review of Decision on Appeal by the Director of Department of Human ServicesLegal  
Multiple Programs  
Open Withdrawal of Request for Hearing (.doc, 1 pp, 522 KB)Open Withdrawal of Request for Hearing (.pdf, 1 pp, 136 KB)Open Withdrawal of Request for Hearing Instructions (.pdf, 1 pp, 17 KB)
13MP004E
H-3Withdrawal of Request for HearingLegal  
Multiple Programs  
Open Resource Family Request for a Fair Hearing (.doc, 1 pp, 681 KB)Open Resource Family Request for a Fair Hearing (.pdf, 1 pp, 164 KB)Open Resource Family Request for a Fair Hearing Instructions (.pdf, 1 pp, 18 KB)
13MP005E
H-4Resource Family Request for a Fair HearingLegal  
Multiple Programs  
Open Discrimination Complaint Form - Client or Vendor (.doc, 1 pp, 545 KB)Open Discrimination Complaint Form - Client or Vendor (.pdf, 1 pp, 81 KB)Open Discrimination Complaint Form - Client or Vendor Instructions (.pdf, 1 pp, 12 KB)
14CR001E
OCR-001Discrimination Complaint Form - Client or VendorCivil Rights  
Open Request for Reasonable Accommodation - Employee or Applicant for Employment (.doc, 1 pp, 668 KB)Open Request for Reasonable Accommodation - Employee or Applicant for Employment (.pdf, 1 pp, 134 KB)
14CR003E
ADA-1Request for Reasonable Accommodation - Employee or Applicant for EmploymentCivil Rights  
Open Request for Reasonable Accommodation - Client or Applicant for Services (.doc, 1 pp, 668 KB)Open Request for Reasonable Accommodation - Client or Applicant for Services (.pdf, 1 pp, 134 KB)
14CR004E
ADA-2Request for Reasonable Accommodation - Client or Applicant for ServicesCivil Rights  
Open Non-Discrimination Compliance (.doc, 1 pp, 658 KB)Open Non-Discrimination Compliance (.pdf, 1 pp, 132 KB)Open Non-Discrimination Compliance Instructions (.pdf, 1 pp, 13 KB)
14CR007E
AA-7Non-Discrimination ComplianceCivil Rights  
Open Discrimination Complaint Form - Employee (.doc, 1 pp, 929 KB)Open Discrimination Complaint Form - Employee (.pdf, 1 pp, 129 KB)
14CR019E
P-019Discrimination Complaint Form - EmployeeCivil Rights  
Open Office of Client Advocacy Intake Referral (.doc, 2 pp, 210 KB)Open Office of Client Advocacy Intake Referral (.pdf, 2 pp, 213 KB)Open Office of Client Advocacy Intake Referral Instructions (.pdf, 1 pp, 23 KB)
15GN001E
OCA-001Office of Client Advocacy Intake ReferralApplications  
Client Advocacy  
Open Local Grievance Coordinator (LGC) Worksheet (.doc, 2 pp, 100 KB)Open Local Grievance Coordinator (LGC) Worksheet (.pdf, 1 pp, 129 KB)
15GR002E
OCA-GR-001-ALocal Grievance Coordinator (LGC) WorksheetClient Advocacy  
Open Notice of Grievance Rights - Hissom Class Members (.doc, 2 pp, 661 KB)Open Notice of Grievance Rights - Hissom Class Members (.pdf, 1 pp, 67 KB)
15GR007E
OCA-GR-3-ANotice of Grievance Rights - Hissom Class MembersClient Advocacy  
Open Quarterly Grievance Report (.doc, 2 pp, 600 KB)Open Quarterly Grievance Report (.pdf, 2 pp, 76 KB)
15GR010E
OCA-GR-006Quarterly Grievance ReportClient Advocacy  
Open Designation of Local Grievance Coordinator - Facilities and Provider Agencies (.doc, 1 pp, 508 KB)Open Designation of Local Grievance Coordinator - Facilities and Provider Agencies (.pdf, 1 pp, 65 KB)
15GR021E
OCA-GR-10Designation of Local Grievance Coordinator - Facilities and Provider AgenciesClient Advocacy  
Open Bodily Injury Chart (.pdf, 1 pp, 79 KB)
15IV002E
OCA-002Bodily Injury ChartClient Advocacy  
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Last Updated:  7/29/2010
Oklahoma Department of Human Services
Street address: Sequoyah Memorial Office Building, 2400 N. Lincoln Blvd., Oklahoma City, OK 73105
Mailing address: P.O. Box 25352, Oklahoma City, OK 73125
(405) 521-3646
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