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Trauma Fund 2018 April

This is for care provided from July 1, 2016 to December 31, 2016.

To apply for Trauma Fund you must submit a complete application by the designated deadline.
To download your items for your application package:
1.  Identify your provider type (EMS, Hospital or Physician).
2.  Select the correct section.
3.  Download the items you need by clicking on the correct items 
    below.

 

NOTE:  APPLICATION DEADLINES ARE DIFFERENT FOR EACH PROVIDER TYPE.  See respective Letter of Invitation for deadline.

 

Emergency Medical Services (EMS) Application
  
Letter of Invitation (288 KB pdf)
  Checklist for Submission (22.4 KB pdf)
  Memorandum of Agreement, MOA (54.6 KB pdf)
  EMS Clinical Criteria (12.9KB pdf) 
  EMS Claim Form (2010.xlsx 24.8 KB)
  EMS Financial Instructions (509.5 KB pdf)
  EMS Worksheet (18KB .xlsx)
  EMS Step-By-Step Guide (29.6 KB pdf)

Hospital Application
  
Letter of Invitation (586 KB pdf)
  Checklist for Submission (58.4 KB pdf)
  Memorandum of Agreement MOA (58.4 KB pdf)
  Hospital Clinical Criteria (13.5 KB pdf)
  Hospital Claim Form (sample) (12.9 KB pdf)
  Hospital-Major Trauma Case List Response Form (sample)(38.8 KB pdf)
  Hospital Financial instructions (23.4 KB pdf)
  Hospital Step-By-Step Guide (54.10 KB pdf)

Physician Application
  
Letter of Invitation (565 KB pdf)
  Checklist for Submission (22.8 KB pdf)
  Memorandum of Agreement, MOA (58.4 KB pdf)
  Physician Clinical Criteria (14.91 KB pdf)
  Physician Claim Form (2010.xlsx 35.3 KB)
  Physician Step-By-Step Guide (50.78 KB pdf)

 

Please e-mail your questions to esystems@health.ok.gov or contact our office at (405) 271-4027.
 

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