Hill, Roosevelt
APPROVAL Of\ PETI'J'ION
FOR ADMISSION TO
A. G. HOLLEY STATE HOSPITAL
STATE OF FLORIDA
Patient or County mutit
arrange and pay tralltipor-
tation to and from hOtipLtal
COUNTY OF-D1 oN (20 f..,.
1n the matter of the application of
;!,j/
Lal:lt
IfoCJSE/JELI
First
Hiddlt.~
for admtl:lslon to the A. G. Ilolley State Hospital.
Tu the Superintendent of Bald 1l0Bpital:
Upon filing of the petition of the above named person and the presentation of the
report of Doctor
j IIwYEI(
Lal:lt
Shu€0
First Middle
Jdy tlhe6-o
City or Town
, Florida,
examining pllysician. that the said applicant is afflicted with tuberculosis:
The Board of County Commisl:doners does hereby grant approval to the application of
sald applicant for admission to the above stated Florida Tuberculosis Hospital, and said
Board does hereby agree to pay to the 1I0spital monthly $1. 25 per diem for the care and
liIaintenance of said appll.cant and the HOBpital will credit this County with Firtit $1..25
collected for each dilY from any source under the Fee Collection Program, Chapter 402.)3.
Florida StatuteB.
The Board of County Commissioners agrees to accept responsibility for any non-rctiident
patient, when he il:l ready for discharge, if the said Board had approved the non-rctildent
patient'l:I admisslon Lo Lhe State Tuberculosis Hospital.
The following action has been initiated by the County:
(1) JlRS Porm 280 completed and forwarded to the Hospital
(2) IIRS Form 280 provided to client with appropriate instructions for complet'lon Clnd
~ubmll:il:lton to the lIol:lpltal.
(3) Other - Please explain:
(SgAL)
ATTEST ~-1d...:-~
Deputy
DATED AT K&>y tJ&>~t", Mnnrn&> r,nl1nty, Fl.
Approved by the Board of County Commissioners
of
Monroe
County, Florida,
Clerk
tHy
Petition approved by: