Donjon, Thomas P.
APPROVAL OF PETITION FOR ADMISSION TO
A. G. HOLLEY STATE HOSPITAL
STATE OF FLORIDA
COUNTY OF
Monroe
LAST
Thomas
FIRST
P.
In the matter of the application of Donlon,
MIDDLE
for admission to A. G. Hospital.
To the Superintendent of said hospital:
upon filing of the petition of the above named person and the presentation of
the report of Doctor Mariners Hospital, Emerqency Room physician, Tavernier , Florida
LAST FIRST MIDDLE CITY OR TOWN
examing physician, that the said applicant is 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 s<!' ir app' i~ant a:')~ tt." h~Ir.~i t...l will ccec1l t
th~s county with first $1. 25 collected for each day from any source in accordance
with 10D-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 10D-57. 342, Flor ida 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.
(SEAL) DANNY L, KOLHAGE, .Clerk
ATrESTLr;2j{~~ /;~~~ I~/
APPROVED BY THE BOARD OF COUNTY COMMISSIONERS OF
MONROE
FLORIDA
COUNTY,
DATED AT Key West, Florida
DATE January 23
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BY: .. ..- ....,... ...
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7
M.D.
/ TH FFICER
, 19~
PETITION APPROVED BY:
HRS Form 1588, Nov. 83