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Offender Housing Invoice <br />(Month) 2015 <br />Total Amount ($00.00) <br />Daily Bed Day Rate: $65.00 <br />Name <br />Doe, Jane <br />Smith, Johnny <br />County Boarder Exchange Days: <br />Jahnsen, Doe <br />TOTAL <br />N.." DOCI Dal eo£ <br />Birt h <br />Doe,Jane 121156 In5M89 <br />Smith,Johnny 121212 2J16n%2 <br />Jahnsen, Doe 555555 1O/3I/l~2 <br />State of Washington <br />Department of Corrections <br />DOC . <br />123456 <br />121212 <br />555555 <br />Dale of Suvice <br />712011015 <br />711011015 <br />81112015 <br />Attachment C <br />(County/Cityrrribal) Jail <br />(Street Address) <br />(Address) (Phone number) <br />Tail Bed Reimbursement Form <br />BILL TO: W A State Department of Corrections <br />Attn: Violator Desk <br />PO Box 41149 <br />Olympia, WA 98504 <br />(360) 725-8620 <br />DOCViolatorbedbillings@DOC1.WA.GOV <br />DOC Sanction/ DOC Sanction Total 1/ of Billed DOC <br />DOB Confinement Endffransfer <br />Total Amount Billed to <br />out <br />Start date Date <br />01 /15/89 7/19/2015 7/21/2015 <br />02/26/62 7/8/2015 7/20/201 5 <br />10/31/92 08/01/15 08/01/15 <br />Medical Reimbursement Form <br />NolDI tof <br />Contr.actor Dol.te&TlDltof <br />Medical hcilityOl RX RXQ ... tilyor l oi Rmtll iOl Treoltmmt ar St.t/ CODI~ctwil b <br />N.me, &: Shength Days RX' COD lactiDg £XX Med ic.u <br />DOC ~off <br />ModKal <br />Gabapenhn30 \lG Tab El mer 7/20/10\5; 3 pills 1231561 Ph .d IB4pm <br />Eri n ino/2015; Sl.joscph's Hospital 1 days Chest Pam Rogm NO am <br />WaHaWaHaGeneral 5 weeks ForognObJed Billie 8flnOl5,HO <br />Hospital Removal Gohat pm <br />K9561 (4) <br />Name Ii <br />DOC <br />ModKal <br />Stoff <br />Cottllded <br />Tammy <br />Williams <br />lin <br />Russell· <br />Tutty <br />5mh <br />Nichols <br />Days DOC <br />2 $130.00 <br />12 $780.00 <br />-1 -$65.00 <br />13 $845.00 <br />("!,,m Copy of Approved Offsile AJIloa.nlof <br />NOlI form lliary Amount <br />Medical C"P',PUI RequestAitadaed.if P.idby Provider byOffeader, JV.Ii1able ~Y,Not <br />CWmForm. iflllY Co ntactor <br />NfA <br />mdlor <br />Y Y S 1.00 $ 12.30 <br />NJA Y S S l;oo.OO <br />N/A Pending 5 tOO $5,000.00 <br />Page 25 of 25 <br />158362 <br />Amount <br />Billt:dto <br />DOC <br />S 11.50 <br />S L500.00 <br />S 1,996.00