The Oklahoma FPWS 1 form is an application for family planning services administered by the Oklahoma Health Care Authority. Designed for individuals aged 19 and older, this form collects essential information to determine eligibility for family planning assistance. Completing every item accurately is crucial to ensure a smooth application process.
The Oklahoma FPWS 1 form is an essential tool for individuals seeking family planning services through the Oklahoma Health Care Authority. Designed for adults aged 19 and older, this application gathers crucial information to determine eligibility for the SoonerPlan program. Completing every section of the form is vital; if additional space is required, applicants are encouraged to attach separate sheets. The form requests details about household members, including names, Social Security numbers, and demographic information such as race and marital status. It also inquires about employment status, income sources, and existing health insurance coverage. To verify identity and citizenship, applicants must submit copies of relevant identification documents, including driver’s licenses or birth certificates. Furthermore, the form outlines the rights and responsibilities of applicants, emphasizing the importance of providing accurate information and reporting any changes in circumstances. This comprehensive approach ensures that individuals receive the necessary support while maintaining transparency and accountability within the system.
STATE OF OKLAHOMA
Oklahoma Health Care Authority
Application for Family Planning Services
This Family Planning Services/SoonerPlan application is used for individuals 19 years of age and older. Please complete every item on this form. If more space is needed, use a separate sheet of paper. Mail the completed application form to Oklahoma Health Care Authority, Attention: FPW SoonerPlan, PO Box 18276, Oklahoma City, OK 73154. If you need assistance completing this form, contact your local Oklahoma Department of Human Services (OKDHS) county ofice.
1.Tell us about everyone living in the household. Show the names as they appear on their Social Security card.
Race - Please use one or more of the following codes to describe your race(s) and or ethnic group: A = Asian; B = Black;
H = Hawaiian/Paciic Islander; I = American Indian/Alaskan Native; S = Hispanic; W = White Sex: M = Male; F = Female
NAME
Relation-
Social
Date of
Marital
SEX
Race
Hispanic
Okla.
U.S.
Tribal name or alien
(irst, middle, last)
ship to
Security
Birth
Status
or Latino
resident
citizen
registration number
person 1
number
Person 1
M
YES
F
NO
2. How do we contact the above household? (Please print)
Street or P.O. Box
mailing address
City
State
Zip
Finding address, if different Street address
Day time
Area code
Home phone number
phone number
Number for messages
Ofice Use Only
Case name
Case no.
County
Supervisor
District
OKHCA Revised 06-01-07
FPWS-1 Pg 1
FPWS-1
3.For all U.S. citizens needing family planning services, identity must be veriied. Please mail a COPY of each person’s drivers license or government issued ID card with picture, school ID with picture, tribal CDIB card, or U.S. military ID card.
4.For all U.S. citizens needing family planning services, citizenship must also be veriied. Complete the information below. If available, mail a COPY of each person’s birth certiicate with this application.
Name (irst, middle, last) of the
Name as shown on their birth
County of
State of
Mother’s maiden name (irst,
household member needing family
certiicate (irst, middle, last)
birth
middle, last) as shown on the applicant's
planning services
birth certiicate
5. Is anyone in the household employed? Yes □ No □ Self-employed? Yes □ No □ If yes, complete the following about each full-time or part-time job or business. Show gross earnings - NOT take home pay.
Employer’s name, address and phone number
or self employment information
Who earns this money?
Gross earnings per pay period?
How often paid? (weekly, every other week, twice a month, monthly?)
Pg 2
6. Does anyone in the household get any other money or income? Yes No Some examples of other income are:
Social Security/SSI
Other Pensions
Support (alimony or child support)
Annuities/Trust
Worker’s Compensation
Veteran’s Beneits
Interest, such as C.D., stocks, bonds
Railroad Retirement
Military Allotment
Royalties/Gas/Oil
Money from friends, relatives, etc.
Unemployment
Rental
Other, specify ____________________________________
If yes, give us the following information.
Name of person
money is for?
Source of money?
How much
money?
How often received?
7. Does anyone needing family planning services have health insurance? Yes No If yes, answer the following:
Insurance company name, address and phone number
Group or
policy
Person
covered
Type of coverage (major medical, dental, HMO, etc.)
Effective
date
Policy holder’s name and Social Security number
Relationship of
policy holder
to insured
Pg 3
Rights and Responsibilities
The information I give on this form is true and correct to the best of my knowledge. I realize if I give information that isn’t true OR if I withhold information, I can be lawfully punished for fraud or perjury. I may also have to re-pay SoonerCare for any medical bills, which were not paid correctly. (28 USC 1746)
I understand that the information I give on this application both verbally and in writing will be checked. I agree to help do that and to let SoonerCare get needed information from government agencies, employers, medical providers and other sources.
I know that our Social Security numbers will be given to other government agencies to get information needed to prove eligibility.
I know I am required to help the Oklahoma Department of Human Services (OKDHS) or the Oklahoma Health Care Authority (OHCA) to identify and locate those absent parents who might be liable for the costs of medical care to me or others in my family receiving SoonerCare.
I give permission for SoonerCare to: (1) collect payments from anyone who is supposed to pay for medical care, (2) share necessary medical information with any insurance company, person or entity who is responsible for paying the bill, and (3) inspect any of my medical records to determine the compensability of claims for services. I also give permission to any of my medical providers or home care providers to give information to the OKDHS or the OHCA to make payment or overpayment decisions.
I agree to tell SoonerCare within 10 days if there are any changes in our income, the people who live in our home, where we live or get our mail, and/or our health insurance.
I know that I can ask for a fair hearing if I think the decision made on my case is unfair, incorrect or made too late.
I also know that my application for SoonerCare cannot be denied because of race, color, sex, age, disability, religion, nationality or political belief.
13.ASSIGNMENT: I do hereby transfer, assign and authorize payment to the Oklaho- ma Health Care Authority (OHCA) all claims I have or may have against health insur- ance or liability insurance companies, or other third parties. This covers all payments for medical services made by OHCA.
Yes No
This Application will be denied if you check NO to this question.
14. Your Signature______________________________ Date _____________
For ofice use only Date received __________________________
ELIGIBLE Yes No
Signature _____________________________
Date _________________________________
PAPENG-SPAPP-2007
Pg 4
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