Form MHCC-15 "Transportation Authorization Certificate" - Connecticut

What Is Form MHCC-15?

This is a legal form that was released by the Connecticut Department of Mental Health & Addiction Services - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2007;
  • The latest edition provided by the Connecticut Department of Mental Health & Addiction Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form MHCC-15 by clicking the link below or browse more documents and templates provided by the Connecticut Department of Mental Health & Addiction Services.

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Download Form MHCC-15 "Transportation Authorization Certificate" - Connecticut

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INSTRUCTIONS
1. Print or Type clearly.
3. Must be submitted within 3 months of service.
2. Transportation must be by least expensive alternative which provides the necessary safeguards.
4. Receiver certification is not an indication of admittance.
FOR BUSINESS OFFICE USE
TRANSPORTATION AUTHORIZATION
STATE OF CONNECTICUT
CERTIFICATE
I.D. NUMBER
DEPARTMENT OF MENTAL HEALTH AND ADDICTION SERVICES
MHCC-15 Rev. 8/07
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
:
PM
TRANSPORTATION
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
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)
(Must be filled out!)
TYPE OF TRANSPORTATION AUTHORIZED (Examining physician must check one)
1. TRANSPORTATION
[ ] Commercial Invalid Coach
[ ] Ambulance
[ ] Other
AUTHORIZED
DATE (Mo., Day, Yr.)
Conn. Medical License No.
SIGNED: (Examining physician)
2.
PHYSICIAN
Provider hereby certifies that patient named above requested
SIGNED: (Authorized treatment provider representative)
3.
TREATMENT
the transportation provided.
PROVIDER
CERTIFICATION
B. RECEIVING FACILITY CERTIFICATION
I hereby certify that ____________________________________________________ was transported to _______________________________________________________
Name of Patient
Name 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.
DATE (Mo., Day, Yr.)
SIGNED: (Receiving facility representative)
4.
RECEIVER
CERTIFICATION
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
INSTRUCTIONS
1. Print or Type clearly.
3. Must be submitted within 3 months of service.
2. Transportation must be by least expensive alternative which provides the necessary safeguards.
4. Receiver certification is not an indication of admittance.
FOR BUSINESS OFFICE USE
TRANSPORTATION AUTHORIZATION
STATE OF CONNECTICUT
CERTIFICATE
I.D. NUMBER
DEPARTMENT OF MENTAL HEALTH AND ADDICTION SERVICES
MHCC-15 Rev. 8/07
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
:
PM
TRANSPORTATION
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
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)
(Must be filled out!)
TYPE OF TRANSPORTATION AUTHORIZED (Examining physician must check one)
1. TRANSPORTATION
[ ] Commercial Invalid Coach
[ ] Ambulance
[ ] Other
AUTHORIZED
DATE (Mo., Day, Yr.)
Conn. Medical License No.
SIGNED: (Examining physician)
2.
PHYSICIAN
Provider hereby certifies that patient named above requested
SIGNED: (Authorized treatment provider representative)
3.
TREATMENT
the transportation provided.
PROVIDER
CERTIFICATION
B. RECEIVING FACILITY CERTIFICATION
I hereby certify that ____________________________________________________ was transported to _______________________________________________________
Name of Patient
Name 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.
DATE (Mo., Day, Yr.)
SIGNED: (Receiving facility representative)
4.
RECEIVER
CERTIFICATION
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