Care Coordination Enrollment

Please complete a release of information form. The forms can be downloaded here.

There are three steps to enrolling. 

  1. Complete the enrollment form below.
  2. Print and complete a ROI form using one of the following methods
    1. scanned email to
    2. faxed to 405-552-0839
  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.

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.