SoonerCare uses this physician order for diapers, pull-ons, liners, underpads, wipes and non-sterile gloves for members aged 4 to 20. The ordering physician records incontinence type, diagnosis codes, mobility, cognitive function and monthly quantities. The form goes to People First Industries, the DME supplier named on it, which completes the prior authorization section at the bottom.
The ordering physician, who must be SoonerCare contracted, completes Sections I to VIII and signs. People First Industries completes the DME supplier prior authorization section.
Download the current version from the source each time; forms change without notice.
Physician Order for Incontinence Supplies Ages 4-20
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The ordering physician must be SoonerCare contracted. The form is marked to be completed by the physician, covering physician and member information, type of incontinence, diagnosis codes, mobility, cognitive function and monthly product quantities, followed by the physician's signature and date.
Yes. HCA-52 covers members aged 4 to 20. For members 21 and above, OHCA lists HCA-52A, the Adult Incontinence Supply Form, on its provider forms page. Both are physician orders for incontinence supplies under SoonerCare.
Yes. OHCA posts both an English and a Spanish version of HCA-52 under the same entry on its provider forms page, Physician Order for Incontinence Supplies Ages 4-20. Either way, the SoonerCare-contracted physician completes and signs the order.