Form MHCC-3 Physician's Emergency Certificate for No More Than 15 Days Care and Treatment in a Hospital for Psychiatric Disabilities - Connecticut

Form MHCC-3 is a Connecticut Department of Mental Health & Addiction Services form also known as the "Physician's Emergency Certificate For No More Than 15 Days Care And Treatment In A Hospital For Psychiatric Disabilities". The latest edition of the form was released in September 1, 2008 and is available for digital filing.

Download an up-to-date Form MHCC-3 in PDF-format down below or look it up on the Connecticut Department of Mental Health & Addiction Services Forms website.

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PHYSICIAN’S EMERGENCY CERTIFICATE
FOR NO MORE THAN 15 DAYS CARE
State of Connecticut
AND TREATMENT IN A HOSPITAL
DEPARTMENT OF MENTAL HEALTH AND ADDICTION SERVICES
FOR PSYCHIATRIC DISABILITIES
410 Capitol Avenue, Hartford, CT 06134
See Section 17a-502 of the General Statutes
General Statutes, as amended, on reverse side of this form.
MHCC-3 REV. 9/08
REPLACES MH-103
Instructions
1. This certificate must be signed by the physician not more than three days prior to its delivery to the Superintendent of the admitting hospital.
2. Date of examination must be within three days of the date of the physician’s signature.
3. Prepare in duplicate – Original to admitting hospital – Duplicate to the examining physician.
4. Use MHCC-15 (Transportation Authorization) to indicate transportation requirements.
SS NO. (Incl. HCFA suf.)
T O: Superintendent
Hospital
EXAMINING PHYSICIAN (name)
PLACE OF EXAMINATION
EXAMINATION DATE
PERSON EXAMINED (name)
ADDRESS (no., and street, town, state, zip)
SEX
BIRTHDATE
BIRTHPLACE (city, state)
MARITAL STATUS (s, m, w, d, sep)
VETERAN (yes, no)
RELIGION
NEAREST RELATIVE, FRIEND OR GUARDIAN (name)
RELATIONSHIP
TELEPHONE
Has this person been notified of
examination (yes, no)
ADDRESS OF RELATIVE, FRIEND, OR GUARDIAN (no., street, town, state, zip)
HISTORY OF PRESENT CONDITION (including type and amount of present medication, if any)
OTHER PERTINENT HISTORY (previous hospitalizations, treatment, suicide attempts, medication)
FINDINGS AS TO PHYSICAL CONDITION
FINDINGS AS TO MENTAL CONDITION (include reasons for opinions stated)
I am of the opinion that the person examined has psychiatric disabilities and is in need of immediate care and treatment in a hospital for psychiatric disabilities, and
(check as appropriate)
The person examined is gravely disabled.
The person examined is dangerous to himself or herself or others.
CONN. MED. LIC. NUMBER
DATE OF SIGNATURE
SIGNED (examining physician)
For
CASE NO.
ADMISSION DATE
ADMISSION TIME
ACCOMPANIED BY (name)
ADMITTED BY (name)
Hosp.
Use
M.D.
PHYSICIAN’S EMERGENCY CERTIFICATE
FOR NO MORE THAN 15 DAYS CARE
State of Connecticut
AND TREATMENT IN A HOSPITAL
DEPARTMENT OF MENTAL HEALTH AND ADDICTION SERVICES
FOR PSYCHIATRIC DISABILITIES
410 Capitol Avenue, Hartford, CT 06134
See Section 17a-502 of the General Statutes
General Statutes, as amended, on reverse side of this form.
MHCC-3 REV. 9/08
REPLACES MH-103
Instructions
1. This certificate must be signed by the physician not more than three days prior to its delivery to the Superintendent of the admitting hospital.
2. Date of examination must be within three days of the date of the physician’s signature.
3. Prepare in duplicate – Original to admitting hospital – Duplicate to the examining physician.
4. Use MHCC-15 (Transportation Authorization) to indicate transportation requirements.
SS NO. (Incl. HCFA suf.)
T O: Superintendent
Hospital
EXAMINING PHYSICIAN (name)
PLACE OF EXAMINATION
EXAMINATION DATE
PERSON EXAMINED (name)
ADDRESS (no., and street, town, state, zip)
SEX
BIRTHDATE
BIRTHPLACE (city, state)
MARITAL STATUS (s, m, w, d, sep)
VETERAN (yes, no)
RELIGION
NEAREST RELATIVE, FRIEND OR GUARDIAN (name)
RELATIONSHIP
TELEPHONE
Has this person been notified of
examination (yes, no)
ADDRESS OF RELATIVE, FRIEND, OR GUARDIAN (no., street, town, state, zip)
HISTORY OF PRESENT CONDITION (including type and amount of present medication, if any)
OTHER PERTINENT HISTORY (previous hospitalizations, treatment, suicide attempts, medication)
FINDINGS AS TO PHYSICAL CONDITION
FINDINGS AS TO MENTAL CONDITION (include reasons for opinions stated)
I am of the opinion that the person examined has psychiatric disabilities and is in need of immediate care and treatment in a hospital for psychiatric disabilities, and
(check as appropriate)
The person examined is gravely disabled.
The person examined is dangerous to himself or herself or others.
CONN. MED. LIC. NUMBER
DATE OF SIGNATURE
SIGNED (examining physician)
For
CASE NO.
ADMISSION DATE
ADMISSION TIME
ACCOMPANIED BY (name)
ADMITTED BY (name)
Hosp.
Use
M.D.
Section 17a-502. COMMITMENT UNDER EMERGENCY CERTIFICATE. EXAMINATION OF PATIENT. DISCHARGE.
RIGHTS TO BE EXPLAINED. HEARING. DUTIES OF HOSPITAL. ORDER FOR DETENTION TO CONTINUE. PRIVATE
HOSPITALS TO NOTIFY COMMISSIONER. IMMEDIATE DISCHARGE OF PATIENT. WHEN. NOTIFICATION OF
NEXT OF KIN.
a) Any person who a physician concludes has psychiatric disabilities and is dangerous to himself or others or gravely disabled,
and is in need of immediate care and treatment in a hospital for psychiatric disabilities, may be confined in such a hospital, either
public or private, under an emergency certificate as hereinafter provided for not more than fifteen days without order of any
court, unless a written application for commitment of such person has been filed in a probate court prior to the expiration of the
fifteen days, in which event such commitment is continued under the emergency certificate for an additional fifteen days or until
the completion of probate proceedings, whichever occurs first. In no event shall such person be admitted to or detained at any
hospital, either public or private, for more than fifteen days after the execution of the original emergency certificate, on the basis
of a new emergency certificate executed at any time during the person’s confinement pursuant to the original emergency
certificate; and in no event shall more than one subsequent emergency certificate be issued within fifteen days of the execution of
the original certificate. If at the expiration of the fifteen days a written application for commitment of such person has not been
filed, such person shall be discharged from the hospital. At the time of delivery of such person to such hospital, there shall be left,
with the person in charge thereof, a certificate, signed by a physician licensed to practice medicine or surgery in Connecticut and
dated not more than three days prior to its delivery to the person in charge of the hospital. Such certificate shall state the date of
personal examination of the person to be confined, which shall be not more than three days prior to the date of signature of the
certificate, shall state the findings of the physician relative to the physical and mental condition of the person and the history of
the case, if known, and shall state that it is the opinion of the physician that the person examined has psychiatric disabilities and
is dangerous to himself or herself or others or gravely disabled and is in need of immediate care and treatment in a hospital for
psychiatric disabilities. Such physician shall state on such certificate the reasons for his or her opinion.
b) Any person admitted and detained under this section shall be examined by a physician specializing in psychiatry within forty-
eight hours of admission as provided in subsection (f) of section 17-206. If such physician is of the opinion that the person does
not meet the criteria for emergency detention and treatment, such person shall be immediately discharged. The physician shall
enter his findings in the patient’s record.
c) Any person admitted and detained under this section shall be promptly informed by the admitting facility that such person has
the right to consult an attorney, the right to a hearing under subsection (d) of this section, and that if such a hearing is requested
or a probate application is filed, such person has the right to be represented by counsel, and that counsel will be provided at the
state’s expense if the person is unable to pay for such counsel. The reasonable compensation for counsel provided to persons
unable to pay shall be established by the Probate Court Administrator and paid from the Probate Court Administration Fund.
d) If any person detained under this section, or his or her representative, requests a hearing in writing, such hearing shall be held
with seventy-two hours of receipt of such request, excluding Saturdays, Sundays and holidays. At such hearing, the person shall
have the right to be present, to cross-examine all witnesses testifying, and to be represented by counsel as provided in section
17a-498. The hearing may be requested at any time prior to the initiation of proceedings under section 17a-498. The hearing shall
be held by the court of probate having jurisdiction for commitment as provided in section 17a-497, and the hospital shall
immediately notify such court of any request for a hearing by a person detained under this section. At the conclusion of the
hearing, if the court finds that there is probable cause to conclude that the person is subject to involuntary confinement under this
section, considering the condition of the respondent at the time of the admission and at the time of the hearing, and the effects of
medication, if any, and the advisability of continued treatment based on testimony from the hospital staff, the court shall order
that such person’s detention continue for the remaining time provided for emergency certificates or until the completion of
probate proceedings under section 17a-498.
e) The person in charge of every private hospital for psychiatric disabilities in the state, shall, on a quarterly basis, supply the
Commissioner of the Mental Health and Addiction Services in writing with statistics which state for the preceding quarter, the
number of admissions of type and the number of discharges for that facility. Said commissioner may adopt regulations to carry
out the provisions of this subsection.
f) The superintendent or director of any hospital for psychiatric disabilities shall immediately discharge any patient admitted and
detained under this section who is later found not to meet the standards for emergency detention and treatment.
g) Any person admitted and detained at any hospital for psychiatric disabilities under this section shall, upon admission to such
hospital, furnish the name of his or her next of kin or close friend. The superintendent of director of such hospital shall notify
such next of kin or close friend of the admission of such patient and the discharge of such patient, provided such patient consents
in writing to such notification of his or her discharge.
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