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Judgment and Sentence Packet Info

Contact Information

Savannah Jones, Administrative Specialist
Health Services Administration

2901 N. Classen Blvd., Suite 200
Oklahoma City, OK 73106

(405) 962-6144 

(405) 962-6102  

(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 Sentence Forms 

The following forms are effective from July 1, 2017 through June 30, 2018.  Please discontinue use of older forms.  These new forms are meant to minimize confusion and standardize all requests.  

Please post these forms where personnel may refer to them or forward to the appropriate department. If your facility has specific requirements about how records are maintained that differ from these instructions, contact us.

Information for Medical Contacts in the County Jail System

No Pre-Approvals Needed

We DO NOT pre-approve outside care for DOC-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.

DOC Inmates

There are 4 categories of DOC inmates.

  1. Sentenced to DOC in a county facility and waiting for a bed in a state facility. These are DOC-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.
  2. DOC 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, a DOC 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.
  3. DOC 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.
  4. DOC contracted inmates. DOC 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

We are no longer able to accept a certified Judgment and Sentence as verification. The Judgment and Sentence must be sent to LARC or MBCC Records. The County Waiting List is the only form of verification that we can accept in order to authorize payment for care. Please wait 2 business days after faxing the Judgment and Sentence to LARC/MBCC before submitting the MNF to us. This will help to ensure that the claims are not rejected because the inmate is not on the County Waiting List (CWL).

Host Facility Requests

Whenever possible, the host facility should be utilized rather than outside medical care for DOC-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 name 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 so it can be logged. This is often done for you by the Host Facility.

If the Host Facility provider suggests that the DOC-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.

Find a Contracted Provider

If you are unable to take the DOC-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. DOC only pays for emergency extractions for DOC-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 HP 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 HP and delays payment to the provider.

New Scripts

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 Medical Notification Form. 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 DOC-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 DOC 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-DOC) please note: If you fax scripts for DOC-ready inmates directly to Diamond, they will be charged against your county account and will not be paid nor reimbursed by this DOC 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 forms directly to HP. They must have our approval before they can pay any DOC claims.

Please advise your provider that they will bill directly to HP as usual using the DOC-ready inmate’s social security number. The billing address is:

HP Administrative Services, LLC
P. O. Box 268928
Oklahoma City, OK 73126-8928

The provider is not to fax a MNF to HP. When a request goes to HP without approval, they just fax it to us. This causes confusion at HP and delays processing of the claims and subsequently, payment to the provider.


Refills do not need the MNF, but may be faxed alone using the refill form. Utilizing refill stickers speeds processing. A single form may be used for multiple DOC-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 Judgment and Sentence 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 faxed in. 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 DOC when the county jail cannot provide the level of medical care that is required. The MTR Form needs to be faxed to DOC Medication Administration at 405-962-6147 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 Administration will make a recommendation. The move request will either be approved and DOC Population will have the inmate transferred into DOC custody or the move will be denied with a recommendation that the county jail seek medical care at the designated Host Facility. DOC Population will schedule the move accordingly if approved.