The Oklahoma Health Care Authority's HCA-12A is the general paper request for SoonerCare prior authorization of medical services such as DME, home health, private duty nursing, vision care, audiology and sleep studies. A prescribing physician meets it when signing the prescription and diagnosis for a member's requested service. The servicing provider then submits it with documentation through the web PA process.
The prescribing physician completes and signs Section I and gives the diagnosis codes, estimated length of treatment and prescription in Section III. The servicing provider completes the member, provider, date span and line-item sections and signs Section IV.
Download the current version from the source each time; forms change without notice.
Prior Authorization Request
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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No. Plans in SoonerSelect, Oklahoma's Medicaid managed care program launched in 2024, use their own prior authorization forms and processes. The HCA-12A applies to SoonerCare services authorized by the Oklahoma Health Care Authority itself, so check the member's enrollment before completing it.
Two signatures are needed. The prescribing physician signs Section I, confirming the prescription and diagnosis entered in Section III, and the servicing provider signs Section IV. The current version of the form is the one revised October 4, 2017.