"Medical Transfer Request to Assessment & Reception" - Oklahoma

Medical Transfer Request to Assessment & Reception is a legal document that was released by the Oklahoma Department of Corrections - a government authority operating within Oklahoma.

Form Details:

  • Released on February 1, 2021;
  • The latest edition currently provided by the Oklahoma Department of Corrections;
  • Ready to use and print;
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  • Fill out the form in our online filing application.

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OKLAHOMA DEPARTMENT OF CORRECTIONS
Medical Transfer Request to Assessment & Reception
Date: ________________ Time: _________________
Requesting Facility: __________________________________________________ Phone #: (____)__________________
Contact Person: _____________________________________________________ Fax #: (____)____________________
Inmate Name: _______________________________________________________ Gender: p M p F
SSN: _________________________ DOB: ___________________ Judgment and Sentence Date: __________________
Primary Diagnosis: __________________________________________________________________________________
Severity Classification: p Mild
p Moderate p Severe
Mental Health Diagnosis: _____________________________________________________________________________
Severity Classification: p Mild
p Moderate p Severe
Check all that apply:
Orthoses/Prostheses:
¨ None ¨ Braces
¨ Shoe Inserts
¨ Hand/Leg Splints ¨ Limbs ¨ Other: ______________________
Aides of Impairment:
¨ None ¨ Glasses
¨ Walker
¨ Cane ¨ Crutches ¨ Wheelchair ¨ Hearing Aide(s)
Impairments:
¨ None ¨ Mental
¨ Speech ¨ Hearing ¨ Vision
¨ Sensation
Activity Limitation:
¨ None ¨ Moderate ¨ Severe
Pending Appointments:
¨ None Date: ____/____/____ Time: ______ AM PM Location: ___________________
Medical Justification for Transfer: ______________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Hospitalizations: p Currently in hospital p Recent hospitalization Name of Hospital:___________________________
State reason: _______________________________________________________________________________________
___________________________________________________________________________________________________
Name of person completing form: _______________________________________________ Title: __________________
* Fax completed form to Medical Services at 405-962-6147. Include any medical notes and a list of medications the
inmate is taking.
To be completed by Medical Services Office:
Received by: _________________________________________________
Date: ______________________________
Medical transfer approved: p Yes p No If “No” state reason: _____________________________________________
___________________________________________________________________________________________________
Comments: _________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Date Assessment & Reception notified: _____________________
2/21
OKLAHOMA DEPARTMENT OF CORRECTIONS
Medical Transfer Request to Assessment & Reception
Date: ________________ Time: _________________
Requesting Facility: __________________________________________________ Phone #: (____)__________________
Contact Person: _____________________________________________________ Fax #: (____)____________________
Inmate Name: _______________________________________________________ Gender: p M p F
SSN: _________________________ DOB: ___________________ Judgment and Sentence Date: __________________
Primary Diagnosis: __________________________________________________________________________________
Severity Classification: p Mild
p Moderate p Severe
Mental Health Diagnosis: _____________________________________________________________________________
Severity Classification: p Mild
p Moderate p Severe
Check all that apply:
Orthoses/Prostheses:
¨ None ¨ Braces
¨ Shoe Inserts
¨ Hand/Leg Splints ¨ Limbs ¨ Other: ______________________
Aides of Impairment:
¨ None ¨ Glasses
¨ Walker
¨ Cane ¨ Crutches ¨ Wheelchair ¨ Hearing Aide(s)
Impairments:
¨ None ¨ Mental
¨ Speech ¨ Hearing ¨ Vision
¨ Sensation
Activity Limitation:
¨ None ¨ Moderate ¨ Severe
Pending Appointments:
¨ None Date: ____/____/____ Time: ______ AM PM Location: ___________________
Medical Justification for Transfer: ______________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Hospitalizations: p Currently in hospital p Recent hospitalization Name of Hospital:___________________________
State reason: _______________________________________________________________________________________
___________________________________________________________________________________________________
Name of person completing form: _______________________________________________ Title: __________________
* Fax completed form to Medical Services at 405-962-6147. Include any medical notes and a list of medications the
inmate is taking.
To be completed by Medical Services Office:
Received by: _________________________________________________
Date: ______________________________
Medical transfer approved: p Yes p No If “No” state reason: _____________________________________________
___________________________________________________________________________________________________
Comments: _________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Date Assessment & Reception notified: _____________________
2/21