Monday, February 2, 2009

January 23, 2006

Louisiana State Penitentiary
R. E. Barrow, Jr. Treatment Center
Referral Slip

Name: Patrick Brasseaux
DOC#: 329406
Housing Unit: Hic 2
Location Seen: West Yard
Referral To: ATU
Date of Referral: 1-23-06
Time of Referral: N/A
Reason for Referral: R To & drainage at Toe Nail & Sloughing of Skin do to removal and cellulitis
Temporary Duty Status: N/A
Temporary Duty Status Expiration Date: N/A
Signature of Health Care Provider: (illegible signature #505)

Louisiana State Penitentiary
R. E. Barrow, Jr. Treatment Center
Health Care Request Form

Inmate Complete This Section Only (If Applicable)
Please Print the following

Name: Patrick Brasseaux
DOC#: 329406
Age: 32
Race: W
Living Quarters: Hic-2
Job Assignment: Special Squad
What is your health care complaint and/or request? My toe is still infected and painful but my statis and treatment are over.

Inmate Signature: (signature)

( )Triage
( )A&T Unit
( )Nursing Unit I/II
( )MD Clinic
( )Dental
( )Mental Health
( )Other

Health Care Provider Assessment
Date: 1-23-06
Location Seen: West Yard
Time Seen: 1650

New Medications Ordered: Tolfanate Cream

Total: 1

HCP# 505
Health Care Provider Signature: (illegible signature)
Physician Signature: (illegible signature)

(X)No Medical Co-Payment
( )Medical Access Fee @ $3.00
(X)Prescription @ $2.00 each
Total $2.00

I understand that in accordance with Dept. Reg. No. B-06-001, I will be charged $3.00 for self-initiated request for health care services and $2.00 for each new prescription written and dispensed to me, with the exceptions noted in the referred regulation. I am aware that if I declare myself a medical emergency and the health care staff finds that an emergency does not exist, I may be given a disciplinary report for malingering or aggravated malingering.

Inmate Signature (signature)
Date: 1-23-06
Witness Signature: (same illegible signature as health care provider)

Note: The money that he is expected to pay for health care and prescriptions comes out of his account with the prison. Which means that either he makes the money through his prison job where he makes all of about $.04 an hour or from the money his friends and family send him. Since Patrick does not have a job in the prison and isn't being paid, the money that pays for his health care comes out of my pocket.

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