Form Dmh 5 72 01 A is a document used to request reimbursement for services rendered to a patient. The form must be completed and submitted along with the appropriate documentation in order to receive reimbursement. Services that may be reimbursed include, but are not limited to, hospital services, physician services, and other ancillary services. Reimbursement rates vary based on the type of service provided and the patient's insurance coverage. This blog post will provide an overview of Form Dmh 5 72 01 A and outline the steps necessary to submit a claim for reimbursement. We will also discuss some of the common pitfalls associated with completing this form. Finally, we will provide links to additional resources where you can find more information about requesting reimbursement for your medical services. Stay tuned!
| Question | Answer |
|---|---|
| Form Name | Form Dmh 5 72 01 A |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | 122C-251, HOSPITALIZATION, Disabilities, DMH |
STATE OF NORTH CAROLINA |
SUPPLEMENT TO EXAMINATION AND RECOMMENDATION FOR |
Department of Health and Human Services |
INVOLUNTARY COMMITMENT |
Division of Mental Health, Developmental Disabilities, and Substance Abuse Services
SUPPLEMENT TO SUPPORT IMMEDIATE HOSPITALIZATION
(To be used in addition to “Examination and Recommendation for Involuntary Commitment, Form
CERTIFICATE
The Respondent, _____________________________________________
requires immediate hospitalization to prevent harm to self or others because:
I certify that based upon my examination of the Respondent, which is attached hereto, the Respondent is (check all that apply):
Mentally ill and dangerous to self
Mentally ill and dangerous to others
In addition to being mentally ill, is also mentally retarded
Signature of Physician or Eligible Psychologist
Address:
City State Zip:
Telephone:
Date/Time:
Name of
Address of
CC:
Clerk of Court in county of
Note: If it cannot be reasonably anticipated that the clerk will receive the copy within 24 hours (excluding Saturday, Sunday and holidays) of the time that it was signed, the physician or eligible psychologist shall also communicate the findings to the clerk by telephone.
NORTH CAROLINA
_______________________ County
Sworn to and subscribed before me this
________ day of ___________, 20__
(seal)
___________________________________
Notary Public
My commission expires:________________
Pursuant to G.S.
TO LAW ENFORCEMENT: See back side for Return of Service
DMH |
SUPPLEMENT TO EXAMINATION AND RECOMMENDATION FOR INVOLUNTARY |
COMMITMENT |
|
Revised September 2001 |
CERTIFICATE TO SUPPORT IMMEDIATE HOSPITALIZATION |
STATE OF NORTH CAROLINA |
SUPPLEMENT TO EXAMINATION AND RECOMMENDATION FOR |
Department of Health and Human Services |
INVOLUNTARY COMMITMENT |
Division of Mental Health, Developmental Disabilities, and Substance Abuse Services
RETURN OF SERVICE
Respondent WAS NOT taken into custody for the following reason:
I certify that this Order was received and served as follows:
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Signature of Law Enforcement Official |
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DMH |
SUPPLEMENT TO EXAMINATION AND RECOMMENDATION FOR INVOLUNTARY |
COMMITMENT |
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Revised September 2001 |
CERTIFICATE TO SUPPORT IMMEDIATE HOSPITALIZATION |