Yr Details

Form Mhcc 15 is an important document for any business that deals with customers. This form helps you track customer feedback and complaints, and can be helpful in improving your customer service. By tracking customer feedback, you can ensure that your company is meeting the needs of your customers and providing them with the best possible experience.

You can find details about the type of form you intend to complete in the table. It can show you the length of time you'll need to finish form mhcc 15, exactly what fields you will need to fill in and a few additional specific details.

QuestionAnswer
Form NameForm Mhcc 15
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other names

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INSTRUCTIONS

1.Print or Type clearly.

2.Transportation must be by least expensive alternative which provides the necessary safeguards.

3.Must be submitted within 3 months of service.

4.Receiver certification is not an indication of admittance.

TRANSPORTATION AUTHORIZATION

CERTIFICATE

STATE OF CONNECTICUT

MHCC-15 Rev. 8/07

DEPARTMENT OF MENTAL HEALTH AND ADDICTION SERVICES

 

FOR BUSINESS OFFICE USE

I.D. NUMBER

A. IDENTIFICATION/AUTHORIZATION CERTIFICATION (To be completed by PHYSICIAN, RECEIVER and/or PROVIDER for ALL transportation)

PATIENT NAME (Last)

 

 

 

 

(First)

(Middle)

 

PATIENT BIRTH DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PATIENT ADDRESS (No. and Street)

(City or Town)

(State) (Zip))

 

 

 

PATIENT SOCIAL SECURITY NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FROM

 

 

 

 

 

 

 

 

FACILITY CODE

 

TOWN CODE

 

 

TIME DISPATCHED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

:

AM

TRANSPORTATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PROVIDED

 

TO

 

 

 

 

 

 

 

 

FACILITY CODE

 

TOWN CODE

 

 

TIME ARRIVED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

:

PM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TRANSPORTATION MUST BE TO A STATE-OPERATED INPATIENT FACILITY

 

 

 

 

 

REASON FOR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. Psychiatrically Disabled

2. Voluntary Psychiatrically

 

 

3. Emergency Substance

 

4. Voluntary Substance

 

TRANSPORTATION

 

 

 

Patient

 

 

 

 

Disabled Patient

 

 

 

Abuse Treatment

 

 

 

 

Abuse Treatment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Must be filled out!)

 

17a-502 (Complete lines 1,2, and 4 below)

 

(Complete lines 3 and 4 below)

 

 

17a-684 (Complete lines 1,2, and 4 below)

 

 

(Complete lines 3 and 4 below)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TYPE OF TRANSPORTATION AUTHORIZED

(Examining physician must check one)

 

 

 

 

 

 

 

1. TRANSPORTATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AUTHORIZED

 

[

] Commercial Invalid Coach [ ] Ambulance

[

] Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

PHYSICIAN

 

DATE (Mo., Day, Yr.)

Conn. Medical License No.

 

SIGNED: (Examining physician)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

TREATMENT

 

Provider hereby certifies that patient named above requested

SIGNED: (Authorized treatment provider representative)

 

 

PROVIDER

 

the transportation provided.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CERTIFICATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B. RECEIVING FACILITY CERTIFICATION

I hereby certify that ____________________________________________________ was transported to _______________________________________________________

Name of PatientName of Facility

for the primary presenting problem of substance abuse or dependence or psychiatric disability by _____________________________________________________________

Name of Ambulance Company

on _________________ at ________________________ [ ] AM [ ] PM

I hereby certify that prior to transporting the patient, the transportation provider obtained approval for transport from this facility.

4.RECEIVER CERTIFICATION

DATE (Mo., Day, Yr.)

SIGNED: (Receiving facility representative)

 

 

PRINTED NAME OF AUTHORIZED OFFICIAL

C. AMBULANCE COMPANY CERTIFICATION (To be completed for ALL Transportation)

I certify that a reasonable attempt was made to obtain payment from the transported patient and to determine that no third party is liable for payment of the transportation expenses. Evidence of these efforts shall be presented to DMHAS upon request.

SIGNATURE OF AUTHORIZED OFFICIAL OF AMBULANCE COMPANY

DATE

D. BUREAU OF COLLECTION SERVICES

(For Bureau of Collection Services use ONLY)

 

 

Did patient have ability to pay at time of admission? [

] YES [ ] NO (If “YES”, provide financial explanation below)

 

 

 

 

RECOMMENDED BY (Name – PRINT or TYPE)

TITLE

FIELD OFFICE

DATE (Mo., Day, Yr.)

SIGNED

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