Free Letter - District Court of Delaware - Delaware

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,%N&N_RN> /(@qegeQQO?\@y·§)O8314JJF Document 5 Filed O1/07/2008 Page 3 of)4 ll-2QQ%
‘ -{)rl\‘(vl‘Ll) \O\l‘LL lt)\l‘L§_g
engr mmm dvetegeir we D _ -
- Delaware Department of Correction
“ HealthCare Services Fee Sheet
Inmate Name · D ; Y r-te` r D -`¢-· E`: sm # .r-‘ —e’‘’`Sf
l _ D · (Last, First MI) (
Facility _ _____*_ Date · · in .=‘`.- i
_ i_.-Chargeable Visit ‘ $4.00 A
'i`' Non Chargeable Visit -0-
( _ Medication Handling Fee ($2.00 X ) S ·
D Total Amount Charged To rymare Account S
Health Care Staff Signature: { · l i``` li - I
I CERTIFYE BY MY SIGNATURE THAT I HAVE RECEIVED THE SERVICES
DESCRIBED ABOVE. _
i " Inmate Signature: ` D Date; =-D DD?";,*/5]} i
` 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 A
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. _ A ` -
Distribution: l " l E
Original: Facility Business Ofriee Posted/Entered by Date
Copy: Inmate Medical Record (yellow) _ i
Inmate
*Only needed if inmate refuses or is unable to sign.
FORM #: 621
3 part NCR I i
(C:Copay.96:For1n.4)

Case1:O7-cv—OO831-JJF D0cument5 Filed O1/07/2008 Page40f4
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Case 1:07-cv-00831-JJF

Document 5

Filed 01/07/2008

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Case 1:07-cv-00831-JJF

Document 5

Filed 01/07/2008

Page 2 of 4

Case 1:07-cv-00831-JJF

Document 5

Filed 01/07/2008

Page 3 of 4

Case 1:07-cv-00831-JJF

Document 5

Filed 01/07/2008

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