Gregory, Louis
APPROVAL OF PETITION FOR ADMISSION TO
A. G. HOLLEY STATE HOSPITAL
STATE OF FLORIDA
COUNTY OF
Monroe
In the matter of the application of Greqorv
LAST
Louis
FIRST
MIDDLE
for admission to A. G. Hospital.
To the Superintendent of said hospital:
Upon filing of the petition of the above named person
the report of Doctor Carraway Robert
LAST FIRST ~... MIDDLE
examing physician, that the said a9plicant is afflicted with
and the presentation of
Key West , Flori~a
c..ITY 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 s2'ic" app' i~ant a:1::! tl'.c h.:,c~it...l will crec11t
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 acton 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.
DANNY L. KOLHAGE, Clerk
(SEAL) APPROVED
ATrEST -/2 L: AIL
FLORIDA
DATE
BY THE BOARD OF COUNTY COMMISSIONERS OF
M:>NroE
COUNTY,
BY:
, 19~
DATED AT
Un.,,.........,. C~:'.'. ~l.
PETITION APPROVED BY:
HRS Form 1588; N~*~ ~,