Healthcare Provider's Certification Form

A Healthcare Provider’s Certification Form must:

a) Be completed for all individuals serving Work Release, Work Furlough, or Weekender sentences for more than 24 hours

b) Be completed less than 45 days before incarceration to assess whether the person is medically fit to serve time in the Maricopa County jails

c) Include Current PPD (within six months), or a negative chest x-ray with a negative symptom assessment

This must be completed less than 45 days before incarceration. You must obtain a Tuberculin Skin Test, or Chest X-Ray as indicated in the form. It typically takes 72 hours to get test back, so allow for plenty of time. You must bring the completed form with you to jail.

Click here for a downloadable copy of the instructions and form.