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.

Clinical Liaison Form

    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.
  2. 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.
  3. Submitter Information
    Enter the information of the person submitting the form.
  4. Patient Information
    Enter the patient information below.
  5. Leave This Blank:

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