Christianson, Uwe
APPROVAL OF PETITION FOR ADMISSION TO
A. G. HOLLEY STATE HOSPITAL
STATE OF FLORIDA
COUNTY OF
Monroe
In the matter of the application of CHRISTIANSON,
LAST
for admission to A. G. Hospital.
Uwe
FIRST
MIDDLE
To the Superintendent of said hospital:
Upon filing of the peti tion of the above
the report of Doctor McEwen, Marianne M.D.
LAST FIRST MIDDLE
examing physician, that the said applicant is afflicted with
named person and the presentation of
Jacksonville , Florida
CITY OR TOWN
tuberculosis:
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 s~ir app' l':!ant a:1~ tt.c h':lc~it...l will cr-ecllt
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 Commissioners agrees to accept responsibility 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 scton has been initiated by the county:
a. HRS Form 280 has been completed and forwarded to the hospital; or
b. HRS Form 280 has been provided to client with approptiate instructions
for completion and submission to the hospital.
c. Other - please explain.
(SEAL) DANNY L. KOLHAGE, Clerk
ATTEST
DATED AT
HRS Form 1588, Nov. 83
APPROVED BY THE BOARD OF COUNTY COMMISSIONERS OF
II1fJ~ ,-, '-
FLORIDA
COUNTY,
P
19U
DATE
TION APPROVED BY:
_. CHAIRMAN
· J~d.e p)M.D.
I CO TB OFFICER