Form Mhcc 15 PDF Details

Navigating the complexities of mental health care in Connecticut can be challenging, particularly when it involves accessing necessary transportation to state-operated inpatient facilities. The MHCC-15 form, an essential document issued by the Department of Mental Health and Addiction Services, is designed to streamline this process, ensuring that individuals needing psychiatric or substance abuse treatment can receive the care they require expediently and efficiently. By meticulously detailing requirements such as the patient's identification, the nature of the transportation, and certifications from the physician, treatment provider, receiving facility, and the ambulance company, the form encapsulates a comprehensive approach to patient transport. Furthermore, it underscores the importance of cost-efficiency and timely submission, dictating that transportation must be both economical and arranged within three months of the service. It also clarifies that receiving this transportation authorization certificate does not guarantee admission, emphasizing a procedural safeguard rather than an entitlement to treatment. This structured protocol serves not only to manage the logistical aspects of transporting patients but also to ensure that the intricate network of healthcare providers operates in unison for the patient's benefit.

QuestionAnswer
Form NameForm Mhcc 15
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesTransAuthorizat ion mhcc 15 state of connecticut department of mental health and addiction form

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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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Type in the essential details in I hereby certify that was, Name of Patient Name of Facility, for the primary presenting problem, I hereby certify that prior to, DATE Mo Day Yr SIGNED Receiving, RECEIVER CERTIFICATION, PRINTED NAME OF AUTHORIZED OFFICIAL, C AMBULANCE COMPANY CERTIFICATION, I certify that a reasonable, SIGNATURE OF AUTHORIZED OFFICIAL, D BUREAU OF COLLECTION SERVICES, Did patient have ability to pay at, and RECOMMENDED BY Name PRINT or TYPE area.

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