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APPROVAL OF PrTTTTON <br />FOR ADMTSSTON TO <br />A. C. HOLLEY STATE UOSPITAL <br />STATE OF FLORTDA <br />Indian River <br />COUNTY OF <br />Patient or County must <br />arrange and pay transpor- <br />LaLion to anti Drum hospital <br />Brothers, James <br />In the matter of the application of <br />Last First Middle <br />for admission to the A. ti'. -Holley State Hospital. <br />To the SuperIntentlent of saLd liohpttal: <br />_. Upon filing of the Petition of the above named person and the presentation of the <br />Silverman Gary R. Vero Beach <br />report of Doctor , Florida, <br />Last FLrst Middle City or, Town <br />examining physiclan, that the said applicant is afflicted with tuberculosis: <br />The Board of County Commissioners does hereby grant approval to the application of <br />said app IIcant for admissLon to the above stated Florida 'Tuberculosis IlospItal, and baid <br />Beard docs hereby arrue to pay to the Hospital. month Ly $1.25 per titem for the cart: and <br />inatntenance of snit! appl [cant and the lluspital will credit this County with I-irsL $1..25 <br />collected for each day from any source under the Fee Collection Program, Chapter 402.33, <br />Florida Statutes. <br />The Board of County Commissioners agrees to accept responsibility for any nun -resident <br />patient, when he is ready for discharge, if the said Board had approved the non-restdtent <br />patiuiq's adiiikslun Lo Lhe SLate Tuberculosis Hospital. <br />The fol.lowLng actl.on has been initiated by the County: Ind&an River <br />(1) IMS Dorm 280 completed and forwarded to the llospital <br />(2) IMS Form 280 provLded to client with appropriate instructions for completion and <br />suhml s:i Lon to Lhe llospital. <br />(3) Other - I'lease explain: <br />(SEAQ Approved by the Board of County Commissioners <br />ATTI.ST a of Indian River <br />County, Florida, <br />Q. 1rk <br />:1 A'I' 1�_� 8j; Dat mber 23, 1985 ly <br />I ICK B. LYONS <br />Petition approved by; <br />County Ilcal.tli 01. f Lour <br />8 <br />