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.
| Question | Answer |
|---|---|
| Form Name | Form Mhcc 15 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names |
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 |
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 |
|
|
|
|
|||||||||||||
|
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!) |
|
|
(Complete lines 3 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