How to Fill Out and Submit the SoonerCare Self-Employment Income Verification Form

The SoonerCare self-employment income form, officially the Self-Employment/Cash Income Statement, is a one-page document the Oklahoma Health Care Authority (OHCA) uses to figure your net business income for Medicaid eligibility. You download it from OHCA, list your gross income and business expenses for the period you’ve been operating, sign it, and send it back with supporting records. Net profit, not gross receipts, is what OHCA compares against SoonerCare’s income limits.¹

Where to Get the Form

The Self-Employment/Cash Income Statement lives on OHCA’s Forms & Guides page as a downloadable PDF in English and Spanish.² Print it and fill it out by hand, or ask for a paper copy at your local Department of Human Services office. If a caseworker is already handling your application or renewal, they can send you one directly.

What to Gather Before You Start

Pull your records together first. The form asks two core questions: how much money came into the business, and how much went back out. If the numbers on the form don’t line up with the documents behind them, the case stalls.

Your SoonerCare case number or Member ID for the top of the form. Leave it blank if you’re a first-time applicant and haven’t been assigned one.
The legal name of the business and the ownership percentage held by each owner.
Gross income records: bank statements, sales ledgers, or deposit records. The form treats gross income broadly, covering sales, cash receipts, crops, commissions, leases, and fees.¹
Expense records: receipts, invoices, and bills for supplies, rent, utilities, insurance, and anything else spent to run the business.
Your most recent federal tax return. If the business has been running for a year or more, Schedule C is the cleanest source for both income and expenses. If you draw a wage or salary from the business, add your last 30 days of pay stubs.¹

A brand-new business without a tax return yet can still complete the form. Report income and expenses for however long you’ve been operating, and back it up with items like a business license, advertising materials, or a business bank account.

Filling Out the Form Section by Section

The form has five numbered sections and a signature line.

Section 1 asks for your case number or Member ID. Existing members renewing coverage enter theirs here; new applicants leave it blank.

Section 2 asks for the business name exactly as it appears on your tax filings or business license.

Section 3 asks for every owner and each owner’s percentage. Sole proprietors own 100 percent. For partnerships or multi-member LLCs, list each owner’s share. OHCA uses these percentages to allocate business income to the correct household.

Section 4 is where the income and expense numbers go, and it splits by how long you’ve been in business:¹

One year or more: check this box and enter total gross business income and total business expenses for the past 12 months.
Less than one year: check this box, state how long the business has been operating, and enter gross income and expenses for that shorter period.

OHCA subtracts expenses from gross income to reach net profit. That net figure, not total sales, is compared against income limits. A net loss counts as zero income from that business for eligibility purposes.

Section 5 asks whether you pay yourself a wage or salary from the business. Check “Yes” if you run yourself through payroll, and attach the last 30 days of pay stubs. Check “No” if you take draws or distributions from profits instead.¹

Sign and date at the bottom. An authorized representative can sign if one is designated on your case.

What Counts as a Business Expense

The form describes business expenses as “your costs of doing business” and gives these examples: supplies, repairs, rent, utilities, seed, feed, business insurance, licenses, fees, payments on the principal of loans for income-producing property, and capital asset purchases. It also tells you to include any other type of business expense not on the list, so the examples aren’t a ceiling.¹

Because Oklahoma uses MAGI methodology, certain above-the-line deductions further reduce countable income. OHCA’s fact sheet specifically lists the deductible portion of self-employment tax, contributions to SEP, SIMPLE, and qualified retirement plans, and the self-employed health insurance deduction.³ These adjustments can bring you under the eligibility threshold even when your raw net profit is slightly above it.

Home Office Costs

If you ran the business out of your home and claimed a home office deduction on your Schedule C, use that same amount as a business expense on this form. The IRS allows a deduction for the business portion of rent or mortgage interest, utilities, insurance, and maintenance, but only for space used exclusively and regularly for business.⁴

What You Can’t Include

Personal expenses that aren’t tied to the business don’t belong on the form. Groceries, personal car payments, and everyday clothing don’t count. Neither do expenses the IRS wouldn’t recognize, like a home office in a room that also serves as a guest bedroom. Inflating expenses to slip under the income limit can trigger overpayment recovery or a fraud investigation, which is a far worse outcome than being over-income.

Submitting the Completed Form

You have three ways to get the signed form and supporting documents to OHCA:

Online upload through your MySoonerCare account at apply.okhca.org. Attach scans or clear photos of the form and any supporting records. This is the fastest option, and you can track document status inside the account.⁵
Fax to (405) 530-3482. Keep the confirmation page.
Mail to the Oklahoma Health Care Authority in Oklahoma City. Send copies only. OHCA states it will not return original documents.

Keep copies of everything you send, whichever method you choose.

Processing and Verification

Once OHCA has your documents, plan on a minimum of 21 business days for processing, and longer during high-volume periods.⁵ Log into MySoonerCare to see whether your document has been received, is under review, or needs attention.

If your submission doesn’t satisfy verification requirements, the portal flags it as needing a new document that “meets the requirements for verification.”⁵ Upload a corrected form or the missing records quickly to avoid delays. Self-employment income is almost always flagged for verification because OHCA can’t cross-check it through the employer wage databases it uses for W-2 workers.

Reporting Changes After You’re Approved

Approval doesn’t end the obligation. If your business income or expenses change significantly, update your case through MySoonerCare, where you can report changes to income, household size, address, and tax filing status.⁵ OHCA may ask for a new Self-Employment/Cash Income Statement with the updated numbers.

Self-employment income moves around, and OHCA expects that. One strong month doesn’t disqualify you if your annual average stays within limits. But consistently earning above the threshold without reporting the change can lead to an overpayment, and the agency may seek to recover the cost of benefits paid while you were ineligible.

If Your Application Is Denied

If OHCA determines you’re ineligible based on the income you reported, you’ll receive a notice of adverse benefit determination. You have 120 days from the date on that notice to request a state fair hearing.⁶ Missing that deadline can get your appeal dismissed.

Complete the Request for State Fair Hearing form from the OHCA website, write out why you believe the determination was wrong, and attach copies of supporting documents such as updated profit-and-loss statements, bank records, or a corrected Self-Employment/Cash Income Statement showing expenses the first review may have missed. Send the appeal to:

Oklahoma Health Care Authority
Grievance Docket Clerk
P.O. Drawer 18497
Oklahoma City, OK 73154-0497
Fax: (405) 530-3444
Email: docketclerk@okhca.org⁶

The usual reason self-employed applicants lose on appeal is insufficient documentation. If the original denial came down because your expenses weren’t substantiated, the appeal is your chance to provide the receipts, invoices, and bank statements that back the numbers on the form. A self-employment ledger, even a handwritten one, that logs each deposit and each expense can decide the outcome.⁷

1
Oklahoma Health Care Authority. SoonerCare Self-Employment/Cash Income Statement
2
Oklahoma Health Care Authority. Forms & Guides
3
Oklahoma Health Care Authority. How We Determine Income
4
Internal Revenue Service. Topic No. 509, Business Use of Home
5
Oklahoma Health Care Authority. SoonerCare Self-Service
6
Oklahoma Health Care Authority. Request for State Fair Hearing
7
HealthCare.gov. Reporting Self-Employment Income to the Marketplace