HomeMy WebLinkAboutWerner, Charles
APPROVAL OF PETITION
FOR ADMISSION TO
A. G. HOLLEY STATE HOSPITAL
COUNTY OF
in 0 f) r< Ot:.
Patient or County must
arrange and pay transporta-
tion to and from hospital
STATE OF FLORIDA
In the matter of the application of tJJferv'lre-
Last
for admission to the A. G. Holley State Hospital.
{!/J;4Lt. €. S
First
Middle
To the Superintendent of said hospital:
Upon filing of the petition of the above
of Doctor f:/)fJfS W ((f t foe D
Last First
named person and the presentation of the report
KEY L~I!.Go , Florida
City or Town
Middle
examining physician, that the said applicant is afflicted with tuberculosis.
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 said applicant and the Hospital will credit this County with First $1.25 collected for
each day from any source under the Fee Collection Program, Chapter 402.33, Florida Statutes.
The Board of County Commissioners agrees to accept responsibility for any non-resident
patient, when he is ready for discharge, if the said Board had approved the non-r~sident
patient's admission to the State Tuberculosis Hospital.
The following action has been initiated by the County:
(1) HRS Form 280 completed and forwarded to the Hospital
(2) HRS Form 280 provided to client with appropriate instructions for completion and
submission to the Hospital.
(3) Other - Please explain:
(SEAL)
A1!rEST~/ ~
Depu ty Clerk
DATED AT Kev West. Monrop. Connty. Fl. Date March 8 , 19 HI)
~1<;B~~~. ~.'")-
Cha~rman
f ,
".t1 "y I M.D.
Health Officer
Approved by the Board of County Commissioners
of
Monroe
County, Florida
Petition approved by:
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