<p> Correctional Risk Services, Inc. County Information Gathering Tool</p><p>County/State: Name of Facility/Jail: Mailing Address: City, State, Zip Code: # of Inmates: County Inmates: ______State Inmates: ______TOTAL Inmates: ______Sheriff’s Department Tel/Fax #’s: Telephone #: ______Fax #: ______Email Address: Sheriff’s Name: Sheriff Chief Deputy’s Name: Sheriff’s Secretary’s Name: Day-to-Day Contact: Name & Title: ______Tele #: ______Fax #: ______Email: ______Name of Primary Hospital Hospital: ______Are there any special discounts or fee arrangements? Inpatient: ______(If so, CRS will need the Provider’s Tax ID #) Outpatient: ______May CRS contact local hospital & physician(s) to inform them of billing/claim payment procedures? Are there any County run services? Ambulance: ______E.g.: Ambulance? Hospital? Clinics? Hospital: ______Clinics: ______Effective Date of Claims Mgmt Date: ______Management? Insurance? Insurance: ______Inmate Excess Insurance Deductible? $ ______Have any optional Coverages been selected? AIDS/HIV: ___; M&N: ___; (Check all that apply) Maternity: ___; Security & Guarding: ___ CRS Admin Fee (%) ______% (Min: _____%) Who does CRS send remittance claims to? Name: ______Title: ______Does County want CRS to review claims Yes: _____ No: _____ prior to effective date? If so, how far back? How far back? ______Who is the PPO Network? PPO: PHCS # of Medical ID Cards # of Cards: ______</p>