Baker Act and Marchman Act forms - Baptist Health South Florida

Request for Involuntary Examination after Stabilization of Emergency Medical ConditionThe following person ____________________________________________________, for whom an involuntary examination has beeninitiated has been evaluated or treated at ____________________________________________________________ Hospital located at________________________________________________________________________________ for an emergency medical condition.a. The person arrived at this hospital at: __________ am pm on _________________________, 20_____.b. The attending physician documented that the person had an emergency medical condition at:____ am pm on _______________, 20__.c. The attending physician documented at __________ am pm on ___________________, 20___That the person’s medical condition had stabilized, orThat an emergency medical condition did not existThis hospital is notifying ___________________________________________________________________________________________, adesignated receiving facility or the psychiatric unit within this hospital, within two (2) hours of the time noted in (c ) above that the personmust be examined by a designated receiving facility and released; or the person must be transferred to a designated receiving facility in whichappropriate medical treatment is available.Within 12 hours of the time noted in (c) above, the designated receiving facility: (check one or both boxes)Shall perform the involuntary examination at this hospital or,Shall, if it has available the appropriate medical treatment, accept transfer of the person.The nature and extent of this person’s current medical problems: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________This hospital, pursuant to federal and state statutes, will provide or secure transport of this person via: ______________________with expected time of arrival of: ___________ am pm on ______________, 20______ unless other methods of transportationhave been arranged as specified: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ __________________ __________________ __________ am pmSignature of Administrator or Designee Credentials Date Time___________________________________________________Typed or Printed Name________________________________________________Name of Hospital* Transfers of persons in a psychiatric emergency must be performed in compliance with the federal EMTALA law. Thiscompleted form must be given to the receiving facility with the form initiating the involuntary examination prior to or atthe time of the transfer of the person with a copy retained in the clinical record. The person shall not be held forinvoluntary examination longer than a total of 72 hours plus the period during which an emergency medical conditionwas declared by the attending physician.See s. 394.463(g), (h), Florida StatutesCF-MH 3102, Feb 05 (obsoletes previous editions) (Recommended Form)BAKER ACT6

Application for Involuntary Emergency AdmissionFor Substance AbuseI, ____________________________ have personally observed the behavior of _________________________________(applicant)(person whose care is sought)And believe he/she meets the criteria for emergency admission for substance abuse assessment and stabilization underchapter 397.6791 F.S. (Marchman Act).INVOLUNTARY EMERGENCY ADMISSION CRITERIA:I believe the person is substance abuse impaired because: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ANDI believe that because of such impairment, the person has lost the power of self control with respect to substance abusefor these reasons: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________:AND EITHERI believe that the person has inflicted or is likely to inflict physical harm on himself/herself or others unless admittedbecause: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________:OR,I believe that the persons refusal to voluntarily receive care is based on judgment so impaired by reason of substanceabuse that the person is incapable of appreciating his/her need for care and of making a rational decision regardinghis/her need for care because: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________:Involuntary Emergency Admission Request:I request that the above named person be admitted for involuntary emergency admission due to substance abuse and aPhysician’s Certificate is attached. The information given in this application is true and correct.Signature of Applicant: _________________________________Date: _______________Time ___________Witness Signature:____________________________________ Date _______________ Time ___________TRANSPORTATION ASSISTANCEThe applicant, the person’s spouse or guardian ( ) are able or ( ) are not able to provide transportation to deliver theperson for emergency admission. The person may be found at: ____________________________________________________________________________. The following information is provided if needed to find the person so they maybe taken into custody for involuntary emergency admission:County of Residence:______________________ Street Address:___________________________________________Age:____________ Race:______________ Sex: ___________ SS# ________________________________________Height: _________ Weight _____________ Hair Color_______ Eye Color: __________Does person have access to any weapons? yes no If yes, describe: ________________________________Is the person violent now? yes no If yes, describe ___________________________________________________Does the person have any pending criminal charges against him/her? yes no If yes, describe_________________Does the person have a legal guardian? yes no If yes, who __________________________________A signed copy of the Physician’s Certificate must accompany the person and shall be made a part of theperson’s clinical record, together with a signed copy of the application.FORM MA-4 See s.397.6791, 397.6793, and 397.6795, Florida Statutes MARCHMAN ACT7

Physician Certificate for Emergency AdmissionMA-5 Physician Certificate for Involuntary Emergency AdmissionI certify that I have personally examined ________________________________________________________on _______________________ at ___________am/pm. Based on my examination, I conclude that the above(date)(time)named person is substance abuse impaired and is appropriate for emergency admission for substance abuse.This examination was performed within 5 days of the date of the application for admission.My relationship to the person is:__________________________________________________________My relationship to the applicant is:_________________________________________________________My relationship to the licensed service provider is:_____________________________________________The person named above meets the following criteria for emergency admission:1. The person named above is substance abuse impaired because:______________________________________________________________________________________________________________________________AND2. Because of such impairment, the person has lost the power of self-control with respect to substance abuse for thesereasons: ______________________________________________________________________________________________________________________________________________________________________________________AND EITHER3. The person has inflicted or is likely to inflict physical harm on himself or others unless admitted because:__________________________________________________________________________________________OR4. The person’s refusal to voluntarily receive care is based on judgment so impaired by reason of substance abuse thatthe person is incapable to appreciating his/her need for care or of making a rational decision regarding his/her need forcare because: _________________________________________________________________________Recommended Level of Care:Hospital Detoxification Center Addiction Receiving Facility Less Restrictive (assessment only)Signature of Physician:____________________________ Date:_______________ Time __________an/pmPrinted Name of Physician:_______________________ Phone #_____________License #______________A law enforcement officer is requested to provide transportation assistance for the said person for emergency substanceabuse admission to the following facility: ________________________________________________________________Located at _________________________________________________________________________.The person’s present location is at: ______________________________________________________If the person’s present location is unknown, the following information is provided to assist law enforcement in finding theperson so they may be taken into custody for involuntary emergency substance abuse admission:County of Residence:______________________ Street Address:______________________________Age:____________ Race:______________ Sex: ___________ SS# ____________________________Height: _________ Weight _____________ Hair Color_______ Eye Color: __________Does person have access to any weapons? yes no If yes, describe: ______________________Is the person violent now? yes no If yes, describe ___________________________________Does the person have any pending criminal charges against him/her? yes no If yes,describe_____________________Does the person have a legal guardian? yes no If yes, who __________________________FORM MA-5 See chapter 397.6793 and 397.6795, Florida Statutes MARCHMAN ACT8