Stechauner, Matthew v. Wall, Edward et al

Filing 13

ORDER that Defendants Danielle Foster and Doctor Wheatley must respond to plaintiff Matthew C. Stechauner's motion for preliminary injunction, Dkt. 4 , by one week from today. Pursuant to an informal service agreement between the Wisconsi n Department of Justice and this court, copies of plaintiff's complaint, motion for preliminary injunction, and this order are being sent today to the Attorney General for service on defendants Foster and Wheatley. Plaintiff should not attempt to serve defendant on his own at this time. Signed by District Judge James D. Peterson on 3/24/2017. (Attachments: # 1 Plaintiff's motion for preliminary injunction and supporting documents, # 2 Complaint, dkt. 1 ) (jef).

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-DEPART.Ml!Nt-OF CORRECTIONS
Oivisiorr of Adult Institutions
• DOC-3035 (Rev. 12/2009)
c

WISCONSIN
Adm. Code
Ch. DOC 316

HEALTH SERVICE REQUEST
AND COPAYMENT DISBURSEMENT AUTHORIZATION

, •

c::> NOTIFY ANY FACILITY STAFF IF YOUR HEALTH CARE NEED IS AN EMERGENCY ~
PRINT FIRST NAME

PRINT LAST NAME

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FACILITY NAME
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COPAYMENT DISBURSEMENT
AGREEMENT BY PATIENT:
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I HOUSING UNIT
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REQUEST SECTION

DOC NUMBER

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TODAY'S DATE

ry

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the following:

• The Department of Corrections shall charge a copayment of $7.50 for a visit (face to face contact) initiated by a patient when a copayment is required.
• I will not be denied care if I am unable to pay the copayment.
•

By signing below, I am initiating a request for disbursement

•

Failure to sign below will NOT prevent the copayment

of my funds for the copayment

at the time of the visit when a copayment

is required.

from being withdrawn from my account following a visit when a copayment is required.

PATIENT SIGNATURE (Indicates requE'st for disbursement of your funds to pay the $7.50 copayment at the time of the requested visit when a copayment is required.)

TO BE COMPLETED

o MEDICAL

BY HSU ONLY

o DENTAL

(Nurse, Doctor/NP/PA)

CharQe Copayment:

0 Yes 0 No

o OPTICAL

AUTHORIZED STAFF SIGNATURE

DATE OF SERVICE

I
HEALTH SERVICE REQUEST SECTION
INSTRUCTIONS TO PATIENT: Be sure to include today's date on top of form. Check the appropriate box and explain your request on the lines provided.
Place all 4 pages of the completed form in the sick call box. The HSU will send a copy back to you indicating that your request has been received.

o HEALTH SERVICES
o PSYCHIATRIST
~OTHER:
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0 INFORMATION

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o Refer to Special

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Needs Nurse/Committee

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COpy - PATIENT AFTER RESPONSE BY HSU

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Case: 3:17-cv-00221-jdp Document #: 7-1 Filed: 03/21/17 Page 2 of 3
O.EPARtMl'NT. Of CORRECTIONS
• Division of Adult Institutions
DOC-3035 (Rev. 12/2009)

WISCONSIN
Adm. Code
Ch. DOC 316

HEALTH SERVICE REQUEST
AND COPAYMENT DISBURSEMENT AUTHORIZATION

~ NOTIFY ANY FACILITY STAFF IF YOUR HEALTH CARE NEED IS AN EMERGENCY
PRINT LAST NAME

PRINT FIRST NAME

<"""

If'

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FACILITY NAME
l

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HOUSING UNIT

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AGREEMENT

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DISBURSEMENT

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REQUEST SECTION

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DOC NUMBER
<

'1

TODAY'S DATE

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BY PATIENT:

I understand the following:
•
•

The Department of Corrections shall charge a copayment of $7.50 for a visit (face to face contact) initiated by a patient when a copayment
I will not be denied care if I am unable to pay the copayment.

•

By signing below, I am initiating a request for disbursement

•

Failure to sign below will NOT prevent the copayment from being withdrawn from my account following a visit when a copayment is required.

PATIENT SIGNATURE

at the time of the visit when a copayment

is required.

(Indicates reques: for disbursement of your funds to pay the $7.50 copayment at the time of the requested visit 'Nhen a copayment is required.)

TO BE COMPLETED

BY HSU ONLY

D MEDICAL (Nurse, Doclor/NP/PA)
Charge Copayment: DYes
AUTHORIZED

of my funds for the copayment

is required.

D DENTAL

DOPTICAL

D No

STAFF SIGNATURE

DATE OF SERVICE

HEALTH SERVICE REQUEST SECTION
INSTRUCTIONS TO PATIENT: Be sure to include today's date on top of fonn. Check the appropriate box and explain your request on the lines provided.
Place all 4 pages of the completed fonn in the sick call box. The HSU will send a copy back to you indicating that your request has been received.

-6] HEALTH
~

OTHER:

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0

SERVICES

o PSYCHIATRIST

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,

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COPIES FROM HEALTH CARE RECORD (list records below)

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rovide a brief descri

lion below of the services

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au desire so that HSU can res

our request appropriately.
DATE RECEIVED:
TO BE STAMPED BY HSU

o Refer to Special

Needs Nurse/Committee

DATE OF HSU RESPONSE

102-f8-17
COpy - PATIENT AFTER RESPONSE BY HSU

Case: 3:17-cv-00221-jdp Document #: 7-1 Filed: 03/21/17 Page 3 of 3

DEPARTMENT OF CORRECTIONS
• Divisio,", of Adult Institutions
DOC-3035 (Rev. 12/2009)

c)

NOTIFY ANY FACILITY STAFF IF YOUR HEALTH CARE NEED IS AN EMERGENCY

PRINT LAST NAME

PRINT FIRST NAME

_--"---

i

FACILITY NAME

_""

COPAYMENT DISBURSEMENT
AGREEMENT BY PATIENT:
I understand

I

HOUSING UNIT

7
TODAY'S DATE

I

I-

I

J

REQUEST SECTION

the following:

The Department of Corrections shall charge a copayment of $7.50 for a visit (face 10 face contact) initiated by a patient when a copayment
I will not be denied care if I am unable 10 pay the copayment.

•

By signing below, I am initiating a request for disbursement of my funds for the copayment

•

Failure to 5:9" below will NOT prevent the copayment

PATIENT

SIGNATURE

MEDICAL

from being withdrawn

at the time of the visit when a copayment

from my account following a visit when a copayment

is required.

is required.

is required.

(Indicates request ~ordisbursement of your funds to pay the $7.50 copayment at the time of the requested visit when a copayment is required.)

TO BE COMPLETED

o

<:>

DOC NUMBER

t

1

•
•

WISCONSIN
Adm. Code
Ch. DOC 316

HEALTH SERVICE REQUEST
AND COPAYMENT DISBURSEMENT AUTHORIZATION

BY HSU ONLY

(Nurse,

o

Doctor/NP/PA)

0

o

DENTAL

OPTICAL

0 No

Charge Copayment:
Yes
AUTHORIZED STAFF SIGNATURE

I DATE OF SERVICE

HEALTH SERVICE REQUEST SECTION
INSTRUCTIONS
TO PATIENT; Be sure to include today's date on top of form. Check the appropriate box and explain your request on the lines provided,
Place aU 4 Dages of the completed form in the sick call box. The HSU will send a copy back to you indicating that your request has been received.

o HEALTH

SERVICES
D'PSYCHIATRIST

D HEALTH CARE RECORD REVIEW
D INFORMATION

D COPIES FROM HEALTH CARE RECORD (List records below)

D OTHER:
Please provide a brief descri

tion below of the services

au desire so that HSU can res and to

our request appropriately.

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REMAINS

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RESPONSE Check appropriate box below,
crscheduled

to be seen in HSU:

D Treated Today

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fJlL\ln

D MD/DO

D NP/PA

D Refer to Psychiatrist

Ig-RN/LPN

D Refer to Special Needs Nurse/Committee

D Refer to PSU

D Place on Optometric Waiting List

D Refer to MPAA for record review appointment or for copies only. (Must be within 30 days 9/ reques!.)
D Non-Medical Problem
WRITIEN RESPONSE

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AFTER RESPONSE

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