CHJ-549 sample.pdf

This document is a Health Care Request form from the Michigan Department of Corrections' Bureau of Health Care. The form is a standardized medical service request form for prisoners, with sections for the prisoner to complete (Sections A through I) and administrative sections for health care staff. The document appears to be a two-sided form with specific printing instructions noted at the bottom of the page, including details about how different parts of the form should be printed.

The form provides a mechanism for prisoners to request medical services, with checkboxes for different types of medical attention including dental, medical, and mental health care. There is a notice to prisoners indicating that health care services may be denied for lack of personal funds, and that any associated costs might be considered an institutional debt. The form includes sections for scheduling appointments, copayment details, and distribution instructions (with white copies going to Health Services and canary copies to the prisoner). The handwritten note "Part 2 only: prints 5/8" from top" suggests specific printing guidance for reproducing this document.