ADHD Evaluation and Diagnosis Now Hiring State-Wide Make A Referral Areas We Serve Frequent Questions Make A Payment Client's Name* Date of Birth for Identified Client* Month Day Year Phone*Is it okay to text this number?* Yes No Email* Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County* i.e. Tulsa, Creek, Washington...Is the identified client a child?* Yes No No but they do have a legal guardian Is the child currently in DHS Custody?* Yes No Name of DHS Case Worker* Phone Number of DHS Case Worker*County of current DHS case* Parent or Guardian Name* First and Last Name Does the identified client have SoonerCare or Medicaid?* Yes, they ONLY have Medicaid No, they do not have Medicaid at all Yes but they ALSO have ANOTHER type of insurance Select ALL insurance coverage that applies to this client - If you are completing this form on a computer hold ctrl or command to select more than one insurance*MEDICAIDAetnaAetna CoventryAlliance CoalAllied NationalBlueCross Blue ShieldChampVACigna EAP ServicesCigna Health and Life Insurance Co.Edison Health SolutionsGPAGroup Benefit Services (GBS)Health SmartHealthcare HighwaysHealthCare Solutions GroupHealthChoiceHealthScopeHealthSmartHealthSmart Benefit SolutionsHumana MilitaryHumanaChoice PPOMedicaMedicareMeritain HealthOPTUM VAThe Kempton GroupTricare EastUMR - Wausau/UHISUnited Health Care/United Behavioral HealthWebTPAFront and Back of All Health Insurance Cards Except Medicaid - Failure to include pictures of ALL insurance cards may delay services.* Drop files here or Select files Accepted file types: jpg, png, jpeg, pdf, Max. file size: 25 MB. If cards are not provided and you incur charges that we are unable to submit to your insurance, you will be responsible for all charges not covered. If you are completing this form on your phone you can take a picture with your camera. SoonerCare/Medicaid ID or Social Security Number* If you do not know the SooneCare/Medicaid ID Number you must enter the client's social security number so we can look up the ID information.Front of Photo ID for Primary Policy Holder* Drop files here or Select files Accepted file types: jpg, png, jpeg, pdf, Max. file size: 25 MB. Allowed extensions: jpg,.png,.jpeg,.pdfPhoneThis field is for validation purposes and should be left unchanged. Δ