Free Sentencing Memo (Supporting Documents) - District Court of Arizona - Arizona

Corrections Corporation of AmericaICentral Arizona Detention Center
usms PRls0NER CONSULTATION REQUEST
Phx Tuc X
SANCHEZ-MACH, JOSE 14448208 USMS Office
Inmate Name: Inmate ID#
07/16/1939
01/31/2006 DOB
Date ot Request OSTEEN, JOHN MD
Providers Name (Please Print)
Reason for referral (pertinent history & physical findings-please print)
EMERGENCY NOTIFICATION ONLY
VIA FACILITY VAN
INMATE C/O CHEST PAIN, HISTORY FO PREVIOUS Ml, SIGNIFICANT DECREASE IN EXERCISE TOLERANCE


Conditions requiring treatment (check all that apply)
_X__1. Emergency and/or life, limb, hearing or sight threatening conditions.
2. Accidental/Traumatic injury incurred whhile in USMS custody.
3. Acute illness,
4. Chronic conditions which are life threatening or, if untreated during the period of USMS custody
would likely lead to a significant loss ot function or death.
___5.Any other medical condition which the evaluating physician believes (if left untreatment during the
period of USMS custody) will cause deterioration ofthe prisoners health or uncontrolled suffering.
Urgency of
consult (please
check one) iX emergency __urgent _ routine __ standard
(going out now) (1»2 weeks) (3-12 weeks) (13wks—6mo)
Consult or test(s)
required: EMERG ENCY EVALUATION AND TREATMENT
Consult Provider
: MMC
Estimated cost of
service:
Contract Approval: Date:
Contract Denial: Date:
Scheduled date/time of appointment;
S
"*‘*Federal law mandates that reimbursement by the Reviewed by: . x
USMS will be based on MedicareIMedicaid rat.es.*‘* Consult Nurse _
f` °’
Qi? I eg? -3 —~··. or- `I
Case 2:04—cr—01029—MHM Document 69-5 Filed O4/12/2006 Page 1 of 1

Case 2:04-cr-01029-MHM

Document 69-5

Filed 04/12/2006

Page 1 of 1