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Form Mhcc 15 PDF 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.

Question	Answer
Form Name	Form Mhcc 15
Form Length	1 pages
Fillable?	Yes
Fillable fields	38
Avg. time to fill out	7 min 55 sec
Other names	TransAuthorizat ion mhcc 15 state of connecticut department of mental health and addiction form

12

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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
MHCC-15 Rev. 8/07

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

How to Edit Form Mhcc 15 Online for Free

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Step 1: Click the button "Get Form Here".

Step 2: You're now able to alter Form Mhcc 15. You possess lots of options thanks to our multifunctional toolbar - you can include, eliminate, or alter the content material, highlight the selected areas, as well as undertake various other commands.

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Type in the essential details in RECEIVER, CERTIFICATION area.

Completing Form Mhcc 15 stage 2

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