ADSAC COVER FORM 2.06 

Please complete this form and return with a copy of your completion certificate.  Turning in an incomplete certificate will result in a denial further delaying your request.    A certificate must contain the level of care (ex. residential treatment, DUI  school) and length of time in the program to be applicable. If the certificate does not state this information, request a letter from the facility and attach this information to the certificate. 

If you want to be informed that your paperwork was received, send the return letter by certified mail. 

It will take approximately three weeks after we receive your forms to process and send a return response. That means about one month from the time you mail it to us and the time the response is returned to you.  Thank you.

Please (PRINT LEGIBLY) complete the following:

Click Here for a PDF Copy of the Form 

IMPORTANT NOTE:  Forms will be returned if any of the requested information is omitted.  This will result in your process being further delayed.

Please complete and return the form to:

Department of Mental Health
and Substance Abuse Services
Attn:  ADSAC Programs
PO Box 53277
Oklahoma City , OK   73152-3277  

ODMHSAS ADSAC Programs
(405) 522-3858
FAX 522-3767