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Addiction Awareness OSCA 11-036 response - REDACTED.pdf

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<strong>OSCA</strong> <strong>11</strong>-<strong>036</strong> Treatment Court Specialized Service Providers<br />

ATTACHMENT 2<br />

THIRD PARTY SAVINGS REPORT<br />

<strong>Addiction</strong> <strong>Awareness</strong> llc will submit a quarterly third party savings report to <strong>OSCA</strong> and each drug court, if requested.<br />

A separate report shall be completed for each quarter services were provided for each drug court. The report is due 30<br />

days following the close of each quarter. At a minimum, the report shall contain the information outlined below.<br />

Report for ____________________ Treatment Court.<br />

Type of Treatment Court Adult/Juvenile/Family (circle one)<br />

Quarter/year being reported: _____________________/________<br />

(July thru Sept.) – (Oct. thru Dec.) – (Jan. thru March) – (April thru June)<br />

Third Party Savings<br />

Potential<br />

Insurance Coverage<br />

Deductible<br />

Co-Payment<br />

Co-Insurance<br />

Medicaid Coverage<br />

Other State Agency<br />

Other<br />

Name of Insurer/Agency<br />

Amount collected for<br />

co-payment<br />

deductible<br />

or<br />

Total amount of<br />

savings to the<br />

Treatment Court<br />

Page 33 of 38

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