Skip to Main Content
I Want To...
Select a Category
Animal Care & Control
Benefits / Wellness
Board of Supervisors
Boards and Commissions
Clerk of the Board of Supervisors
Correctional Health Services
Public Defense Services
Regulatory - Planning & Development
Regulatory Group Common Forms
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.
Sign in to Save Progress
Clinical Liaison Form
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.
Enter the information of the person submitting the form.
Relationship to Patient
-- Select One --
Health Care Provider
Enter the patient information below.
Date of Birth
Date of Birth
Criminal Case Number
Reason for contacting Correctional Health Services
Leave This Blank:
Receive an email copy of this form.
This field is not part of the form submission.
* indicates a required field
▲ Back to top
Slideshow Left Arrow
Slideshow Right Arrow