Care Coordination Enrollment

There are three steps to enrolling. 

  1. Review the Nursing Privacy Practice Form.
  2. Complete the consent and enrollment form below.
  3. Schedule a phone visit with your care coordinator to complete your enrollment. As a reminder, you are not enrolled until all the paperwork is received and you have completed an enrollment call with the nurse care coordinator.

Please call with any questions you may have: 405-951-2504.

Please complete the consent form below prior to filling out the remainder of the form.

By consenting to participate in the Care Coordination Program, you agree to provide information at the time of enrollment and periodically thereafter which will assist in data collection, assessment, and the determination of an individualized plan of care.
Last, First, Middle Initial
Street, City, State, ZIP
Check all that apply.
Dependent Information

If you are enrolling a covered dependent (spouse or child), please complete the following.

Last, First, Middle Initial
Only if different from above.