Skip to main content

Section 14

OP-140106

OP-140107

  • DOC 140107 A "Worksheet for Monthly Medical Activity Report"

OP-140108

  • DOC 140108 A "Authorization for Release of Protected Health Information"
  • DOC 140108 B "Revocation of Authorization for Release of Protected Health Information"
  • DOC 140108 H "Accounting Of Disclosure Form"
  • DOC 140108 I "Acknowledgement of Request for Protected Health Information" 
  • DOC 140108 J "Request for Correction/Amendment of Protected Health Information" 

OP-140111

OP-140112

OP-140113

OP-140114

  • DOC 140114A "Medical/Mental Health Screening"
  • DOC 140114C "Initial Intake and Routine Physical Examination"
  • Attachment A "Initial Physical Examination and Laboratory Requirements - Male"
  • Attachment B "Initial Physical Examination and Laboratory Requirements - Female"

OP-140115

  • Attachment A "Periodic Physical Examination and Laboratory Requirements Male"
  • Attachment B "Periodic Physical Examination and Laboratory Requirements Female"

OP-140116

OP-140117

OP-140118

  • DOC 140118A "Daily/Monthly AED/Narcan Inspection Log"
  • Attachment A "Non-Medical Facility Staff Administration and Access to Naloxone (Narcan)"
  • Attachment B "Probation and Parole Officer (PPO) and Office of Inspector General (OIG) Agent Administration and Access to Naloxone (Narcan)"

OP-140119

OP-140121

  • DOC 140121 B "Health Care Leave Request" 
  • DOC 140121 C "Rules for Health Care Leave and Medication" 
  • DOC 140121 D "Affidavit for Financial Responsibility for Medical. Mental Health, Dental and/or Vision Care" 
  • DOC 140121 E "Record of Treatment by Community Health Care Provider" 
  • DOC 140121 G "After Clinic Hours-Transfer to ER" 

OP-140124

OP-140125

OP-140127

  • DOC 140127 A "Mental Health Unit, Intermediate Housing Care Unit or Habilitation Program Referral Form"
  • DOC 140127 B "Evaluation Summary"
  • DOC 140127 C “Oklahoma Department of Corrections Mental Health Unit Intake”

OP-140129

OP-140130

OP-140132

OP-140133

  • DOC 140133A "Orthoses, Prostheses and Other Aids to Impairment Appliance Record"

OP-140137

  • Attachment A "Severity Classification of Common Chronic Illness"
  • Attachment B "Chronic Illness Management Guidelines-Routine and Annual Treatment Guidelines"
  • DOC 140137 A " Chronic Clinic and/or Routine/Physical Examination"
  • DOC 140137 B " RN/LPN Chronic Clinic Note"

OP-140138

  • DOC 140138 A “Living Will/Advance Directive for Health Care” 
  • DOC 140138 B “Notification of Activation for a Living Will/Advance Directive and/or DNR” 
  • DOC 140138 C “Do Not Resuscitate (DNR) Consent Form”

OP-140140

  • Attachment A "Mental Health Administration and Organization" 

OP-140141

  • Attachment A "Procedures for Four/Five Point Therapeutic Restraints" 
  • DOC 140141 A "Authorization for Application of Therapeutic Four/Five Point Restraints”
  • DOC 140141 B "Restraint Medical Flow sheet”
  • DOC 140141 C "Physical Restraint Log "
  • DOC 140141 D “Certification Checklist for Safe/Therapeutic Seclusion/Restraint Cell”
  • DOC 140141 E "Therapeutic Seclusion Watch Log"
  • DOC 140141 F "Therapeutic Seclusion Conditions/Precautions" 

OP-140142

  • Attachment A "Provider Peer Review Criteria" 
  • Attachment B "Qualified Mental Health Professional Peer Review Criteria"

OP-140146

OP-140147

  • Attachment A "Male to Female (MtF) Hormonal Therapy Risk and Information Form" 
  • Attachment B "Female to Male (FtM) Hormonal Therapy Risk and Information Form"
  • Attachment C "Request for Gender Dysphoria (GD) Evaluation/Treatment Algorithm"
  • DOC 140147A “Referral for Gender Associated Requests”

OP-140201

  • Attachment B "Mental Health Service Levels Classification System Criteria" 
  • DOC 140201A "Mental Health or Mental Status Review"
  • DOC 140201 B “Mental Health Assessment for Segregation Housing”
  • DOC 140201 C "Abnormal Involuntary Movement Scale"
  • DOC 140201 D "Facility Needs Assessment and Strategic Plan Format"

OP-140301

OP-140652

  • DOC 140652A "ODOC Involuntary Medication Report"
  • DOC 140652B "ODOC Notice of Hearing to Consider Recommendation of Involuntary Administration of Psychotropic Medication"
  • DOC 140652C "ODOC Medication Review Committee Report"
  • DOC 140652D "ODOC Involuntary Medication Hearing - Staff Representative Fact Sheet"
  • DOC 140652E "ODOC Involuntary Medication Appeal Request"
  • DOC 140652F "ODOC Involuntary Medication Appeal Decision"

OP-140701

  • DOC 140701 A "Consent for Medical, Dental and Mental Health Treatment" 
  • DOC 140701 B "Vaccine Administration Consent/Refusal Form" 
  • DOC 140701 C "Neuroleptic's Informed Consent"
  • DOC 140701 D "Informed Consent for Telemedicine Services"
  • DOC 140701E "Consent for Pain Treatment with Controlled Substances; Inmate Agreement"
Last Modified on Jul 28, 2021
Back to Top