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Application ChecklistInstructions:1. Please check each box below, as appropriate; and2. The completed checklist must be submitted as the first page of the CON application. Attached is the CON application
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01
Start by collecting all the necessary information such as the patient's personal details, medical history, and any relevant contact information.
02
Fill out the necessary sections of the form such as the patient's vital signs, symptoms, and any initial assessments or interventions that have been performed.
03
Provide detailed information about the events leading up to the cardiac arrest, including any witnessed collapses or pre-existing conditions that may have contributed.
04
Document any attempts at resuscitation or use of medical equipment, including the administration of CPR, defibrillation, or medication.
05
Use clear and concise language when describing the sequence of events and any response or changes in the patient's condition.
06
Make sure to sign and date the form once it has been completed, and securely store it in the appropriate medical records for future reference.

Who needs for ohca use only?

01
The 'for ohca use only' form is typically needed by emergency medical personnel or healthcare providers who are involved in the management and treatment of out-of-hospital cardiac arrest (OHCA) cases.
02
This form allows them to accurately record and communicate vital information about the patient's condition, events leading up to the cardiac arrest, and the actions taken during resuscitation attempts.

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For OHCA Use Only: template instructions

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For ohca use only is a designation indicating that the information provided is strictly for use by the Oklahoma Health Care Authority.
Health care providers and facilities that submit claims or reports to the Oklahoma Health Care Authority are required to file for ohca use only.
To fill out for ohca use only, simply mark the designated sections or documents with the phrase 'for ohca use only'.
The purpose of for ohca use only is to protect sensitive health care information and ensure that it is only accessed by authorized personnel.
Any information related to claims, reports, or personal health information that is submitted to the Oklahoma Health Care Authority must be reported for ohca use only.
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