Judgment and Sentence Packet Information
Judgment and Sentencing Forms
Savanna Jones, Administrative Specialist
Medical Services Administration
3300 N. Martin Luther King Ave.
Oklahoma City, OK 73111
(Outside care notification and refill forms should be faxed to the above listed number. For the conservation of paper, a cover sheet is not necessary for any requests)
Judgment and Sentencing Forms
The following forms are effective from July 1, 2020 through June 30, 2021. Please discontinue use of older forms. The new forms are meant to minimize confusion and standardize all requests.
Please post the forms where personnel may refer to them or forward to the appropriate department. Contact us if your facility has specific requirements about how records are maintained that differs from these instructions. Please read carefully as these instructions were modified from last year's packet.
- Non-Formulary Pre-Approval Request Form
- Medical Notification Form
- Diamond Pharmacy Services Emergency Prescription Request Form
- Medical Care at DOC Host Facility Request Form
- Patient Refill Form
- Medical Transfer Request to Assessment & Reception
- HB3336 County Jail Algorithm - Outside Medical Care
- HB3336 County Jail Algorithm - Medical Care at ODOC Host Facility
Information for Medical Contacts in the County Jail System
No Pre-Approvals Needed
We DO NOT pre-approve outside care for ODOC-ready inmates. Your local/jail provider will make the determination as to whether an inmate needs to be seen by another outside provider/specialist, including dentists. When possible, make specialty appointments with your Host Facility; or make the local appointment and send us the Medical Notification Form (MNF) AFTER the inmate has been seen. The county jail is responsible for providing routine medical, mental health, and dental care in accordance with State Statute Title 57-38.3.
There are 4 categories of ODOC inmates.
- Sentenced to ODOC in a county facility and waiting for a bed in a state facility. These are ODOC-ready inmates that this program covers. We are given a list of those “waiting” in county by Lexington Assessment and Reception Center (LARC) for male inmates and Mabel Bassett Correctional Center (MBCC) for female inmates. Outside medical care and medications for these inmates are submitted to us as outlined below.
- ODOC in a state facility that have been returned to a county facility at the county’s request in order to face additional charges. These are the responsibility of the county as the county has chosen to house the inmate while they wait for court rather than transporting them back and forth between court and the prison. On a rare occasion, an ODOC inmate who has been sentenced but is still in county will also be awaiting further charges. These are also the responsibility of the county until such time as they have been sentenced on the last charge outstanding. If the charges are dismissed, the most recent Judgment and Sentence (J&S) applies. Inmates that have returned to the county for a delayed sentence hearing will be the responsibility of the county.
- ODOC in a state facility. When they are brought out of county and given bed space in a state facility. These are covered under a different funding source.
- ODOC contracted inmates. ODOC currently has two contracts with county jails. These inmates are considered to be incarcerated in the “prison” even though they are in a county facility and are covered under the same funding as those in #3 above, not this program.
Certified Judgment and Sentence
If the inmate is not listed on the “County Jail Waiting List” (COMIT) with a J&S received date on or before date of service requested, the county jail will be responsible for cost of outside medical care and medications.
Host Facility Requests
Whenever possible, the host facility should be utilized rather than outside medical care for ODOC-ready inmates. The Request for Medical Care at DOC Host Facility Form should be faxed directly to the Host Facility assigned to your jail to request appointments. Find your county on the included Host Facility Responsibility List and fax your request form to the appropriate facility. We do not need a copy of that request. The Host Facility will forward these forms to us after the inmate has been seen. Please discontinue use of the old forms that do not have the check box in the lower right that indicates if scripts were ordered.
You should also send a completed MNF or bring the MNF to the appointment. Medications prescribed will be listed on the form by the medical staff and are usually ordered by the Host Facility directly from Diamond Pharmacy Services. Have the provider sign the form and date it with the date of service. It should be faxed to us after the inmate has been seen for logging. This is often done for you by the Host Facility.
If the Host Facility provider suggests that the ODOC-ready inmate needs to see a specialist outside of the state facility, you must file a MNF with us after the appointment in the same manner as you would for all other outside care. The Host Facility does not do this for you. Once the form is complete, email it to Savanna Jones or fax it to (405) 425-2911.
Find a Contracted Provider
If you are unable to take the ODOC-ready inmate to a Host Facility, cannot get an appointment in a reasonable period of time, or the condition worsens before your Host Facility appointment, you may take the inmate to a local provider.
Please check the provider listing for a contracted provider in your area. Looking under provider search by zip code with a mileage range seems to be the easiest way. You can then look for specialists as needed.
NOTE: Any non-contracted providers will be paid at Medicaid rates.
There has been a lot of confusion about dental, particularly about wisdom teeth. ODOC only pays for emergency extractions for ODOC-ready inmates. The general mindset is that many dental pain issues can be relieved with proper dental hygiene and/or antibiotics. The first step should be to have the inmate see the local/jail medical provider. If there appears to be a serious issue, the provider can prescribe meds while you try to make an appointment with dental at the Host Facility. If the dentist at the Host Facility deems further action is needed, they will either make the arrangements or give you guidance in making them yourself. It is important that you allow the Host Facility to make the determination of care as Healthscope will not pay for routine exams and cleanings, dental surgery, root canals, crowns, fillings, etc. It will end up being a cost to your facility.
If antibiotics do not appear to be working and your appointment is still pending, or a long time out, you can seek care locally with a contracted provider. After the appointment, send us a MNF completed as you would for any other outside medical care. The care given by the provider must be noted in the comments section to include the number of the teeth extracted, if appropriate.
Remember that any care other than the exam and/or an emergency extraction is not covered by the contract the provider has with us and will be denied. This means the charges will be the responsibility of the county and/or the inmate.
Medical Care and New Prescriptions
The MNF must accompany any new prescriptions, as well as all outside medical care requests. Do NOT use a form that did not arrive in this packet. These forms can be preprinted with your facility information for ease of use. A master can also be created with the personal information for each inmate who has maintenance meds for even faster completion. Please write out the provider/hospital name. The local abbreviations only cause confusion with Healthscope and delays payment to the provider.
For scripts, only the Jail Administrator portion needs to be completed and medications can be listed in the Health Care Provider section. This must be signed by either the provider or the in-jail medical personnel who are authorized to transcribe medication orders. If a Patient Care Form and/or script pad is used and signed/stamped by the provider, they will not need to sign the MNF. If we receive script requests by 2pm, they will be delivered the next business day.
There are some prescriptions that have multiple formulas, most notably Hydroxyzine which is available as Pamoate or HCL and regularly ordered for ODOC-ready inmates. Please ensure that the orders you are submitting have the proper formulation, complete dosage, frequency notations that are clearly legible for Diamond Pharmacy Services. These are the most common reasons for clarification requests and delays in filling meds.
NOTE: In the event of an emergency need for medications (meds that should be started before the next regular delivery), you may fill the script at the approved local pharmacy for a 7-to-14-day supply. Complete a Prescription Payment Authorization Form and provide it to the pharmacy. The “Prior Authorization Number” is the code assigned to your facility by Diamond Pharmacy Services. This is also the code that you put at the top of your refill forms. The local pharmacy will bill ODOC directly.
If the medication is needed for longer than 7 – 14 days, it may not qualify as urgent. In the case that it does qualify as an emergency medication (provider discretion), a separate script will need to be submitted to us for regular processing for the additional meds needed past 14 days.
DO NOT fax any initial orders or refills directly to Diamond Pharmacy Services! DO NOT have providers or medical facilities fax orders to Diamond Pharmacy Services! Diamond Pharmacy Services must have our approval before they can fill any scripts. If it does not come through us first, it only causes confusion and delays.
If you currently use Diamond Pharmacy for your county inmates (non-ODOC) please note: If you fax scripts for ODOC-ready inmates directly to Diamond, they will be charged against your county account and will not be paid nor reimbursed by this ODOC program.
If Diamond Pharmacy Services has faxed you for clarification on a medication or to notify you that they do not carry a medication that was ordered, you can respond to them directly. If you have to change the medication or dosage, then you must resubmit that change to us first, so that it has approval on it.
Outside Medical Care, Emergency Care, and Hospital Admission
For outside medical care, complete the Jail Administrator and the entire Health Care Provider section, including an explanation of why outside care was sought. Please ensure the provider signs the form. A copy of the patient care or discharge form should be included for outside care and a copy of the scripts is always appreciated, if available.
Check the box for Outside Medical Care, Emergency Care, or Hospital Admission as appropriate. Ensure that the date in the Health Care Provider section is the Date of Service. If ambulance transport was utilized, a separate MNF for that service will need to be submitted with the transport company information in the Health Care Provider section, signed by jail personnel. Forms for Outside Care, Emergency Care, and Hospital Admissions must be received by us within 24 hours of the date of service. By statute we can deny the claim if the forms are not received in a timely manner. This would make the cost of services the responsibility of the county and/or the inmate.
- DO check the Prescription box if the provider listed in the Health Care Provider section wrote a prescription as well. Please ensure the provider signs the form. We will look for scripts and process them with Diamond Pharmacy Services unless the notes at the bottom of the form indicate that they were filled by the provider, or if an emergency, at a local pharmacy.
- DO NOT fax MNF directly to Healthscope. They must have our approval before they can pay any ODOC claims.
Please advise your provider that they will need to submit CMS 1500 Health Insurance Claim Form to the billing address below:
Department of Corrections
P. O. Box 16532
Lubbock, TX 79490-6532
If you have any questions, you can reach Customer Care at 800-323-3710 or by fax 833-559-8614. The EDI # is 71065.
Refills do not need the MNF, but may be emailed to Savanna Jones or faxed to (405) 425-2911 alone using the refill form. Utilizing refill stickers speeds processing. A single form may be used for multiple ODOC-ready inmates. Do NOT fax ANY script forms directly to Diamond Pharmacy Services. They must have our approval to process any prescriptions.
Non-Formulary Drug Medications
All non-formulary drug requests will require a J&S Non-Formulary Pre-Approval Request Form completed by the prescribing provider if they wish for an inmate to remain on the medication. This will need to be attached with the MNF and emailed to Savanna Jones or faxed to (405) 425-2911. All non-formulary drug requests will require the approval of our Chief Medical Officer or a designated Psychiatrist.
This is our most recent Drug Formulary List.
Medical Move Requests
A Medical Transfer Request (MTR) is required for an inmate that is awaiting transfer to ODOC when the county jail cannot provide the level of medical care that is required. The MTR Form needs to be faxed or emailed to ODOC Medical Services Administration at (405) 425-2911 or firstname.lastname@example.org for review and approval. Make note that this is a different fax number then the Prescription/Outside Medical Care/Emergency Care/Hospitalization requests are sent.
The county jail inmate will have to be on the county jail waiting list that is maintained by Lexington Assessment and Reception Center and Mabel Bassett Assessment and Reception Center. Please make sure that the MTR Form is filled out completely and is legible. Provide as much information as possible to help determine if the request for move is a valid request. You will also need to include a medication list and any medical/hospital notes that would justify a medical move.
Once the county jail waiting list is verified, DOC Medical Services Administration will make a recommendation. The move request will either be approved and ODOC Population will have the inmate transferred into ODOC custody, or the move will be denied with a recommendation that the county jail seek medical care at the designated Host Facility. ODOC Population will schedule the move accordingly if approved.
If you have a question regarding a medical transfer, please call ODOC Medical Services Administration at 405-425-2307.
Please keep a copy of these procedures on file and post the example forms to help any new personnel who may be assigned to you.