Form Center

By signing in or creating an account, some fields will auto-populate with your information and your submitted forms will be saved and accessible to you.

Clinic Liaison Form

  1. The Correctional Health Services (CHS) Clinical Liaison is a non-emergency service for sharing health-related information. During regular business hours, Monday - Friday 8:00 AM - 5:00 PM, your message will be forwarded to clinical staff where the patient is housed for follow-up.

  2. Submitter Information

  3. Patient Information

  4. Leave This Blank:

  5. This field is not part of the form submission.