Thanks for your response. I have to apologize for not put enough info about the form online. The preprinted portion of the form not only includes "General Hospital 'Okolona'" as I indicated earlier, but also includes a line that begins "At Meridian, Miss.," followed by the hand written date and other relevant info. Sorry about having left that part off.
I've posted the form online for those who may like to examine the document at:
I initially thought as you did, that a correct/acurate form was not available. I was researching Surgeons J. D. Caldwell and Walter Curry for my story on Marion Confederate Cemetery. I have nothing further about the individual who is being discharged.