Looking for a U.s. Department Of Health And Human Services Forms And Templates? Download it for free!

Form Aa-5 - Application For And Authorization Of Temporary Involuntary Hospitalization - Massachusetts Department Of Mental Health Page 2

COMMONWEALTH OF MASSACHUSETTS

DEPARTMENT OF MENTAL HEALTH

Authorization Pursuant to Section 12 (b)

Designated Physician* Authorization :

(NOTE: Boxes A. through G., below, must be checked to authorize a Section 12(b) involuntary

admission to a facility.)

I am a designated physician* of the aforementioned facility with authority to

authorize admissions under Section 12 (b).

I have personally examined this person

within 2 hours of his/her arrival at the facility

more than 2 hours after his/her arrival at the facility due to the fact that I was engaged in

an emergency situation.** The emergency situation was:

and I examined the patient at

am/pm.

This person does not require emergency or inpatient medical or surgical care.

I have offered this person an application for Care and Treatment on a Conditional Voluntary

Basis and the person:

(one of the two boxes below must be checked to proceed with a Section 12(b) authorization)

refused to sign, or

the application was rejected (the reasons why the application was rejected must be

stated on the application and the rejected application shall become part of this

person’s medical record at the facility).

Note:

104 CMR 27.07 (1) requires that the patient be offered an opportunity to change to

conditional voluntary status again within three days of admission.

I concur with the applicant’s recommendation and have completed a psychiatric

examination to support this conclusion. Alternatively, I am the applicant, I have

personally examined this person, and have completed sections 1), 2), 2A) and 2B)

on the opposite side of this form.

In my opinion, at the present time there is no less restrictive placement that is appropriate for

this person to which he or she is willing to go.

I authorize this person’s admission.

I reject this application for admission for the following reasons:

Designated Physician’s Name (print):

Phone:

Address:

Designated Physician’s Signature:

Date: ___________________________________

Time: _____________________________

A physician who meets the criteria in 104 CMR 33.03

** See 104 CMR 27.07 (2)

Form AA-5

Effective – September 25, 2013

Form Aa-5 - Application For And Authorization Of Temporary Involuntary Hospitalization - Massachusetts Department Of Mental Health Page 2