Skip to Main Content
Loading
Loading
I Want To...
Services
Departments
Home
Form Center
Form Center
Search Forms:
Search Forms
Select a Category
All Categories
Accessibility
Air Quality
Animal Care & Control
Benefits / Wellness
Board of Supervisors
Boards and Commissions
Clerk of the Board of Supervisors
Communications
Contact
Correctional Health Services
Emergency Management
Employment
Environmental Services
Facilities Management
Finance
Flood Control
GIS
Human Services
Improvement Districts
MCDOT
Medical Examiner
OET
Permitting
Planning & Development
Procurement Services
Public Advocate
Public Defense Services
Public Fiduciary
Public Health
Real Estate
Regulatory - Planning & Development
Regulatory Group Common Forms
Regulatory Outreach
Risk Management
Waste Resources
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.
Clinical Liaison Form
Sign in to Save Progress
This form has been modified since it was saved. Please review all fields before submitting.
COVID-19 EFFORTS - CORRECTIONAL HEALTH SERVICES
COVID-19 Efforts: To prevent or mitigate the potential spread of COVID-19 in any of the Maricopa County Sheriff Office (MCSO) jails, proactively, Maricopa County Correctional Health Services (CHS) is following the precautions recommended by the Maricopa County Department of Public Health and the CDC. View precautions and live updates on our COVID-19 dashboard.
CHS Clinical Liaison Contact Form
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.
Submitter Information
Enter the information of the person submitting the form.
Last Name
*
First Name
*
Phone
*
Email Address
Relationship to Patient
*
-- Select One --
Legal Representative
Relative
Case Manager
Friend
Court Staff
Health Care Provider
Patient Information
Enter the patient information below.
Last Name
*
First Name
*
Date of Birth
Date of Birth
Booking Number
Criminal Case Number
Reason for contacting Correctional Health Services
*
Leave This Blank:
Receive an email copy of this form.
Email address
This field is not part of the form submission.
Submit
* indicates a required field
Arrow Left
Arrow Right
[]
Slideshow Left Arrow
Slideshow Right Arrow