Insure Oklahoma/O-EPIC Subscriber Application

Online Insure Oklahoma/O-EPIC Program Participation Agreement

Thank you for your interest in the Insure Oklahoma/O-EPIC Program.

 

In order to complete the application you must read and understand the information in the box below.

 

If you agree with the terms of Program Participation, please select “I Agree”. This allows you to continue completing the application.

 

If you do not agree with the terms of Program Participation, you may select “I Do Not Agree”. By doing so you will not be able to continue completing the application.

 

More detailed information on Program Participation can be found at www.insureoklahoma.org or by calling the Helpline toll-free at 1-888-365-3742 or for the hearing impaired, call the TDD line at (405) 416-6848.

By clicking “I Agree” you agree that 

  • You are voluntarily choosing to participate in the Insure Oklahoma/O-EPIC Program.
  • You will be responsible for paying the appropriate premiums and out-of-pocket costs including but not limited to co-payments.
  • You understand you will not be eligible for traditional SoonerCare programs (Medicaid) or additional state sponsored coverage while enrolled in the Insure Oklahoma/O-EPIC Program.
  • If you have children that you are enrolling in Insure Oklahoma, you are required to help the Oklahoma Department of Human Services (OKDHS) or the Oklahoma Healthcare Authority (OHCA) to identify and locate those absent parents who might be liable for the cost of medical care to the children you are enrolling.
  • I authorize Insure Oklahoma to use my and the members of my family's Social Security Number (SSN). By agreeing to this consent to disclose my SSN, I authorize Insure Oklahoma to use and to disclose my SSN to others if it is necessary to confirm my eligibility.
  • I authorize Insure Oklahoma to contact other people and agencies to verify my eligibility for the program.
If in the future you wish to enroll in a SoonerCare program, you can apply anytime. If accepted, you will no longer be eligible for the Insure Oklahoma/O-EPIC Program and will not be refunded premiums or out of pocket expenses previously paid.