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2 4d }t+t 0,t Ch Case 2:17-cv PLM-TPG ECF No filed 10/05/17 PageID.83 Page 2 of MIOHICAN DEPARTMENT OF CORRECTIONS-Bureau of Health Care CHJ /05 HEALTH CARE REQUEST c..o,_j-+11<llif. ~.-a_ t,jc...{ 1-fu,C PRISONER:.COMPLE E SECTIONS A THROUGH D LOCK: ~ /-z._( DATE: This Health Care Request is for the following (check one or more): DHealth Record Copies 0 Non-urgent D Dental D Medication Refili ~dical D Optometry DMental Health l1j-1jrgent 1havethefollowingprob1ems1symptoms: o;j Cf,ltff1.:t Wu.) Plucfv ad f., r> /Jo..t-..µ, B) \\J{ 1-- b{ ~:_rr:~!u~c19j>{l-ftf<j;~;f '\>tjl...}.:. (u.v\t1/t ]_ t yoo~~ ~~0 NOTICETOPRISONER &'fr/;._/o>-iw ~cj/( or-k. ()~ Jl'{ y... oo +,(cr.r IJ\j-Std +ll'- 6-1-)\t.Jl 1=-'-01) copayment will be considered an institutional debt and shall be collected as s71 forth ip PD , "Prisoner Funds". "T-A"'-l{ o~..+tq_ \l... r ldl'"foo/( hl) tj-qµj; Md' r1v,~;<.j.:>f::i-j,~v7:jt-lrrf...rr.fcof Signing this document formally requests treatment. In addition, it authorizes the DOC to treat or arrange treatmedt for you and to release any necessary medical information to facilitate that treatment, to review treatment, to respond to a related grievance, or to review any appeal you may make regarding the Department's decision to charge for the care. ~ fi..,j Ji J J'-f kd 6c.Jc 1 ~;.fi l uu yj ::r- \11- \ y rt"v\) +.l-0.1.( Y}f- lfttt-'1 Cu.. v.lz.lllij\ ""'Y IA.a._y ~ /.ft++j\l/tfojla.k.. J"(..v'tH utj I have read Section D above, or it has been read to me and I understand that I will be charged $5.00 for my health care visit nless it i for one of the reasons listed below in Section F. Ifl am charged for this visit, I agree that the $5.00 may be taken from my account. Prisoner Signature:

3 ri_tlj,;tr'1i.jj~ I :) - ;:,r Case 2:17-cv PLM-TPG ECF No filed 10/05/17 PageID.84 Page 3 of 6 MICHIGAN Dn1ffiM'E'Nt OF CORRECTIONS-Bureau of Health Care LOCK: 3~ tl-lj This Health Care Request is for the following (check o~e or m9re ): DHealth Record Copie~ ~di cal 0 Optometry DMental Heal COPAYMENT Note: Care that is: / D Signature: Distribution:

4 lj Case 2:17-cv PLM-TPG ECF No filed 10/05/17 PageID.85 Page 4 of 6 / I have the following problems/symptoms: (f f>w -ifil..;_ 1 (.JI~ I 1J ~ ~1.,.,..'. Jc1:..P~ cy & i ' " AJ I-Ir.f f)j..-1 I!:../ J. l'..!c:p.~ 1. Ju rl' ~tit~ dt:..dr'fe-'1..c J'.:Luz oj; v NOTICE TO PRISONER j) '(. _f,,~ <.J ' fl~ $;> 1-1-' U Cf c;> ''7 l ff_-fl.f K/_a copayment will-be considered an institutional d bt and shall be collec ed as set foyth in PD 04.0).105 "Prisoner Fund!!'.'... :rj:i.. >9-,,.:\ C...Vc...,_ c..ln-t cy p-r,.00< P< p!'fa} ~~ 1 rh ( ~ Yli"t' Signing this document formally requests treatment. In addition, it authorizes the DOC to treat or arrange tr&tment for y9u and to release any necessary medical information to facilitate that treatment, to review treatment, to respond to a related grievance, or to review ; my ap. peal you may make regarding the Department's decision to charge for the care..l9,(_,... \ SJ- { / ( H U}i.'fS.-µ,,._ J_ S,1f oier}1.~} iµl G 11 JC'f}.. 6-t Jr r cj. 91.0J S'Wµflu{ I have read Section D above, or it has been read to me and I understand that I will be charged $5.00 for my health care visit unless it is for one of the reasons listed below in Section F. Ifl am charged for this visit, I agree that the $5.00 may be taken from my account. Prisoner Signature: "'ff(., 1 (1 ~ t"ft'ljt/;;.j.k. 1J1'-'"J Da~ M< :;;'c)1v.p5;..ji.{ INSTRucnoNs To PRISONER ~- > (,,,,2,..1 Yt\{ tcs o 1..f I:) w r,f S. e 0-d Py /..f;.f.;;it/:, w 1 lc:s.. ro/~ 1.Q1 +h r-> O 1c:1t'tc 't1c ~~Q,~ 1R c,j/-,-j c 1 1.J.2 J- ()t-pj 1 An appointment has been scheduled fos you on: Signature: Title: Provider#: Date: COPAYMENT (to be filled out by health care): C>t-kr)-li'[. ~ j<~{i vt...1,; Qo-w10 s;:'..j::!::;r,.> Note: If none of the exceptions listed below 'apply, check the_box below and~ copay will be charged. i Care that is: D Signature: Distribution: requested by a QHP (includes transfer assessments,.chronic care --- clinics, intake and annual screening, ~~d.r~q~ired follow-up care) :rt-f2._ ; ~r_i-f _Ce>,4-/-t*'<.JO\.l)l'{ 't{,ti:~.:...f~l~'([u + for mjunes that are work-related as documented bj.: the pnsoner's work supervisor 6-- c::./;) p '(),.f h}o Ni.J + requested for testing for HIV, STD's, infestations, or reportabte communicable disea t ""T':.. If \.J<Jh J'0 + requested for evaluation, consultation, or treatment-of a ment,al health need / 1.i. + prompted by a medical emergency (see Section I of the pojjcy, if self-inflicted) IJ-Atcv ~ fcu ( o I' -tjf I have reviewed the visit of and certify none of tlittse exceptions apply. Sir(C[. ""fl'!v '(.. ' Date..,,,,,,~ " " '-,. _, "V"(J7 J.11 f!: Title: Provider#: Uo W ;{ ( te;...:_....

5 ,,. Case 2:17-cv PLM-TPG ECF No filed 10/05/17 PageID.86 Page 5 of 6 MICHlGAN DEPARTMENT OF CORRECTIONS -Bure~rrtlT""1"11'r~ITITf' 1~,...,.---- HEALTH CARE REQUEST FACILITY: LOCK: DATE: q- /~17 This Health Care Request is for the following (check one or more): DHealth Record Copies D Non-urgent 0 Medication Refill ~ical 0 Optometry DMental Health rgen, I have the following problems/symptoms: Q N ~ - 2 Cf ( 7 1 f;: () ( kv I t tf r J J+ Jc { ~ f-f le/ ±=l1 I 5. {.5 ~Viv f 01..1/. ;;) /CI}'( e vhcl(/./ I rlj }'1-'1V f)j(/l I ~ +-r II JV P011/?nu i6 f.. rlt-;_ (<,j rl~ J,.,/ ii.i I f J 1 / 5 / < o)! J-t 7 -t NOTICE TO PRISONER )'Vl A...( /~A_p- / u K fl-('/ 4--{ 1 /( ~C11 VJ /--jrj1 (.i l/~ ( Y f <J~ copayment will be considered an institutional debt and shall be collected as set forth in PD p4.02. l 05, "Prisoner Fu~qs". 111 l /"L 1 /( ~ u \~ \j> 01 ) () ~ o../ ~ 10fl- ~... z r- t7,,,, 1.. vr l/c '/ p c1 -",. #J#/5 C/J Signing this document formally requests treatment. In addition, it authorizes the DOC to treat or arrange trea(ment for you and to release any necessary medical inforrr_iation to facilitate that tr~a~ment, to review treatment tq._respond to a;elat d grievance;tr to review any appeal you may make regardmg the Department's dec1s10n to charge for the care. If' V1/I.; IJ /1P$ I rfc-~ ~ /r!u J 1Jr f.-1 Yu i> /f_n TJ 1 'j/ocj,( Vvu )1 )-1(.e., y ~ >h I '/3~fr-r..vt. 1--/ 1.. (~ JJ11J/-u/j I have read Section D above, or it has been read to me and I understand that I will be charged $5.00 for my health care visit unless it is for one of the reasons listed below in Section F. Ifl am charged for this visit, I agree that the $5.00 may be taken from my account. Prisoner Signature: 5 J j i J t: µ) / I ~ ~ I I I VI/ j.:,,,.,,,j T,<.., e-1 ~ CC-t f J?: If Al_ af:! ~-I-ht',; '---'1-' 9 /

6 MICHIGAN Case DEPARTMENT 2:17-cv PLM-TPG OF CORRECTIONS-~ureau ECF No of Health filed Care 10/05/17 PageID.87 Page 6 of 6CHJ /05 HEALTH CARE REQUEST NAME: NUMBER: LOCK: ~-ll DATE: This Health Care Request is for the [ollowing (check one or more): DHealth Record Copies D Dental D Medication Refill C!l1'.i'edical D Optometry DMental Health Non-urgent rgent ' NOTICE TO PRISONER (.(;#- -;f:" (.,,..(tlfj- ~ \)~Si.c.. J':.. 'fc,\.j -by ft.tcdc.uµ~ '(c-11 {(N~ o~ co payment will be considered an institutional deg.t and shall be collected as set forth in PD , "Prisoner Funds". -\-l\..._ r,~c:y ~~~~ ~~ ~.Cc-d!... "{ <4t c.."-"'-{c..:.lc...'{ ~ Cc /- Signing this document formally requests treatment. In addition, it authorizes the DOC to treat or arrange treatment for you and to release any necessary medical information to facilitate that treatment, to review treatment, to resptllld to a related grievance, or to review any appeal you may make regarding the Department's decision to charge for the care-:- 'IJ.(A:.IJ /1.-(;...-cfc.c_ "- ( S' +.-c.. J<JC t...llt / ( 1) ~1 ~1(c...dt. V1-v -6'-( lvte<.lcuh.!1 y,(j kn'!.~ ( 0-...f dlt-:._ &c.{..\...> 3.t ~ 'fc.c... /J( Sr:n:t1 I have read Section D above, or it has been read to me and I understand that I will be charged $5.00 for my health care visit unless it is for one of the reasons listed below in Section F. If1.am charged for this visit, I agree that the $5.00 ma be taken from my account. PrisonerSjgnature: )'vl '~l<...j.l ~~ ~(C,.{JC.. I~ I.(.,lf ~)J~r Y0t1 ~~ ~ i.j.n.jt.!y"11 PRISONER: DO NOT WRITE BELOW THIS LINE l.jlot-p r 5"tr '("~JI\ INSTRUCTIONS TO PRISONER / J An appointment has been scheduled for you on: Signature: Title: Provider#: Date: COPAYMENT (to be filled out by health care): ~ Note: If none of the exceptions listed below apply, check the box below and a copay will be charged. Date: Care that is: requested by a QHP (includes transfer assessments, chronic care clinics, intake and annual screening, and required follow-up care) for injuries t~at are work-related as documented by the prisoner's work supervisor requested for testing for HIV, STD's, infestations, or reportable communicable diseases requested for evaluation, consultation, or treatment of a mental health need prompted by a medical emergency (see Section I of the policy, if self-inflicted) 0 I have reviewed the visit of and certify none of these exceptions apply. Date Signature: Title: Provider#: Distnbution: White - Health Services, Canary - Prisoner, Pink - Business Office..,~ Date: