Betancourt, Harry A.
APPROVAL OF PETITION FOR ADMISSION TO
A. G. HOLLEY STATE HOSPITAL
STATE OF FLORIDA
COUNTY OF
Monroe
In the matter of the application of Betancourt,
LAST
Ha rry
FIRST
A
MIDDLE
for admission to A. G. Hospital.
To the Superintendent of said hospital:
Upon filing of the petition of the above
the report of Doctor hilrr;rI'IPC: Ian
LAST FIRST
examing physician, that the said applicant is
named person and the presentation of
I Key Wpc:.t. Flil , Florida
MIDDLE CITY OR TOWN
afflicted with t;berculosis:
1. The Board of County Commissioners does hereby grant approval to the
application of said applicant for admission to the above stated Florida Tuberculosis
Hospital, and said Board does hereby agree to pay to the hospital monthly $1.25 per
diem for the care and maintenance of S2'ir app' i'::'ant l!:1~ tt.(; h.:.t;LJit....l will credIt
th~s county with first $1. 25 collected for each day from any source in accordance
with 100-57.341, Florida Administrative Code.
2. The Board of County Conuniss ioners agrees to accept responsibili ty for a
patient in accordance with 100-57.341 and 100-57.342, Florida Administrative Code,
when he is ready for discharge, if the said Board had approved the patient's
admission to the State Tuberculosis Hospital.
3. The Board of County Commissioners agrees that the patient or county shall
arrange and pay transportation to and from hospital.
4. The following Acton has been initiated by the county:
a. HRS For.m 280 has been completed and forwarded to the hospi tal; or
b. HRS Form 280 has been provided to client with approptiate instructions
for completion ano submission to the hospital.
c. Other - please explain.
(SEAL) DANNY L. KOLHP...GE, Clerk
ATTEST
APPROVED BY THE BOARD OF COUNTY COMMISSIONERS OF
/1t,..,., 1-,
FLORIDA
COUNTY,
DATED AT
DATE ~-~
BY, ~r:'-~'~f.,
, 19
PETITION APPROVED BY:
CHAIRMAN
,..
,
HRS ,..",/'1"" . ..0;..., Nov. 83