Free Answering Brief in Opposition - District Court of Delaware - Delaware

I Case 1 :06—cv—0001 1-SLR Docurgent 67-5 Filed 08/25/2006 Pagee 1 of 4
. . DCC Delaware orrectional Center Da :08/03/2006
Smyrna Landing Road - _ g
SMYRNA DE, 19977 ci " . I
Phone No. 302-653-9261 #-D if
GRIEVANCE INFORMATION - Appeal

Offender Name :BAYLlS, LEONARD K SBI# : 00100231 Institution : DCC
Grievance # : 22328 Grievance Date : 11/29/2005 Category : Individual
Status : Unresolved Resolution Status : |¤m=·1I¤ SIRIUS 1
Grievance Type: Health Issue (Medical) Incident Date : 11/29/2005 Incident Time : 13:00
IGC : ll/lerson, Lisa I\/I Housing Location :Bldg 23, Lower, Tier D, Cell 3, Bottom

_ l,Appeal arrived Thursday 3 August 2006: It has been well over a year since I have been scheduled to have dental work -
_ However no actual dental work has been accomplished.
I I appeal tothe grievance board for an investigation vis a vis actual dental work vs. words on paper. This to the extent that I I
lactually receive dental work.
. I am experiencing stomach problems because of difnculty chewing food and digesting food. gg X


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Page 4 of 6 4.

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_ Case 1:06-cv-00011-SLR Document 67-5 Filed 08/25/2006 - P/age 2 0f4 - `
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` .·—../ l -=~· - ` Delaware Department of Correction
. - ` _ - Health Care Services Fee Sheet -
_ Inmate tits Q; l :§f§s;'_3g‘;-ij; p SB] # l. hg? '-e‘ if
··-j(Last, First MI) UK fg, QNM? -· 24 sr?--·:= és
.- D vq·e.9£#m~ ·
. Date
idx Chargeable Visit _ $4.00
___ Non Chargeable Visit U -0- "
___ Medication Handling Fee ($2.00 X ) S . t;F‘t°`>;
Total Amount Charged Tolnmate Account $ { 23S .
Health Care Staff Signature: sic; ig? .
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I CERTIFY BY MY SIGNATURE THAT I HAVE RECEIVED THE SERVICES - i
-- _ _ DESCRIBED ABOVE. _L I
.- Inmate Signature: _}Pg I _`”_ _.__ ,__a '__4'_·P\ W I ' _ Date: _,._ $2;;: t
1) *Witness Signature: Date: · __ _ _
2) *Witness Signature: Date: ` A:
The fee for services rendered will be deducted from your inmate account even if the amount
deducted generates a negative balance. Any funds received by you will tirst be applied to any
negative balance. Any negative balance remaining on your account when you are released will
remain active for three (3) years after the date of release. Should you return to Delaware Department
of Correction as an inmate within that three (3) year period, the negative balance will be applied to
= ` your inmate account on your new commitment. `
p Distribution: _
Original: Facility _Business Office POSt€d/EHil€I€d by Date
Copy: Inmate Medical Record (yellow)
Inmate (pink)
*Only needed if inmate refuses or is unable to sign. - `
··‘` FORM #2 621 .
- 3 part NCR .
U - (C:Copay.96:FormA)

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_ Case 1:06-cv-00011-SLR Document 67-5 Filed 08/25/2006 Page 3 of 4 I I I
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· A ` Delaware Department of Correction
~ ` Health Care Services Fee Sheet
‘ Inmate Name ti`:-e:Lj`.g-i .i_ -¤:JJ·· SBI # f€T[j_Z2= .f$Elg` -
. lliast, First MI) U 4)_¤(g‘*”C'£_`f Y-¤-V D"`?6$ HJT l
. 4 ` f{)€{?c}-l·u··-C I (/4*.: :*6} p »
Facility 1. l Date ia _»’ `0'{ {Z . i
` _ #_r,»Chargeable Visit $4.00 I
- __»_;" Non Chargeable Visit -0-
_ _ Medication Handling Fee ($2.00 X ) $ A s
is Total Amount Charged To Inmate Account S I
Health Care Staff Signature: n lé (gg ‘ · ip-
I CERTIFY. BY MY SIGNATURE THAT I HAVE RECEIVED THE SERVICES
_ DESCRIBED ABOVE. ·
i l Inm-atc Signkllturld: - Date; lilly W I- V- T
` 1) *Witness Signature: Date: ·
2) *Witness Signature: Date:
The fee for services rendered will be deducted from your inmate account even if the amount
deducted generates a negative balance. Any funds received by you will first be applied to any
negative balance. Any negative balance remaining on your account when you are released will l —
remain active for three (3) years after the date of release. Shouldyou retum to Delaware Department
of Correction as an inmate within that three (3) year period, the negative balance will be applied to
your inmate account on your new commitment. _ -
Distribution: ` · _ A .
Original: Facility Business Office Posted/Entered by _ Date
Copy: Inmate Medical Record (yellow)
Inmate (pink)
*Only needed if inmate refuses or is unable to sign. A
FORM #: 621 ‘ (
3 part NCR _ . ·
_ (C:Copay.96:Form.4) .

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- Delaware Department of Correction ( -
` Health Care Services Fee Sheet Q
l Inmate Name il *3 sn. -‘A‘ ;o..i"`é“¢f SBI # F .5
(Last, First MI) Q iycggyif? D¤·q·¢—¢ {-:1 t l
A ‘ttD”`S i?Q§£> rt r c »e»-» i t..a A
Facility Ll" U Date ij} i?<..t¤:=-
_ Chargeable Visit $4.00 ` `
- ` Non Chargeable Visit -0- _
% Medication Handling Fee ($2.00 X ) S
_ . _ Total Amount Charged To Inmate Account S
—{;·*"'; Alf U n`
Health Care Staff Signature: g,,g’ t
I CERTIFYH BY MY SIGNATURE THAT I HAVE RECEIVED THE SERVICES F l
DESCRIBED ABOVE. _ E. _
Inmate Signature: -"-- - - a·a‘ S ._ -.``- e··‘‘li ·.---- . ._ Date: ”`ii ig iii f*~·—“!k>¢¢=
1) *Witness Signature: Date: · _ . _
- 2) *Witness Signature: i Date: ;‘
The fee for services rendered will be deducted from _your inmate account even if the amount
deducted generates a negative balance. Any funds received by you will first be applied to any
negative balance. Any negative balance remaining on your account when you are released will
remain active for three (3) years after the dateof release. Should you return to Delaware Department _
of Correction as an inmate within that three (3) year period, the negative balance will be applied to
_ your imnate accotnit on your new commitment. V
- Distribution: `
Original: Facility Business Office Posted/Entered by Date
- _ Copy: Inmate Medical Record (yellow) ;
Inmate (pink)
*Only needed if imnate refuses or is unable to sign. (
‘ FORM #1 621 J
3 part NCR . A
` (C:Copay.96;Form.4) l g