Free Letter - District Court of Delaware - Delaware

Case 1:04-cv-00361-JJF Document 17-4 Filed 08/01/2005 Page 1 of 1
Delaware Department of Correction
Health Care Services Fee Sheet
Inmate Name SBI #
(Last, First Ml)
Facility Date
__ Chargeable Visit $4.00
__ Non Chargeable Visit -0-
__ Medication Handling Fee ($2.00 X ) S
0 21 11101111 H1` C 0 111113 E CCOIIII _
T ( I A t Ch g CI T I t A t S
Health Care Staff Signature:
I CERTIFY BY MY SIGNATURE THAT I IIAVE RECEIVEI) THE SERVICES
DESCRIBED ABOVE.
A Inmate Signature: Date:
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 bc applied to any
negative balance. Any negative balance remaining on your account when you are released will
remain active for three (3) years alter 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 imitate account on your new commitment.
Distribution:
Original: Facility Business Office I)OSl€Ci/El‘tiC1‘€ti by I-)£dl€
Copy: Inmate Medical Recon} (5 ellov.)
Inmate (pink)
*Only needed ifinmate refuses or is unable to sign. i
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Case 1:04-cv-00361-JJF

Document 17-4

Filed 08/01/2005

Page 1 of 1