Baker Act and Marchman Act forms - Baptist Health South Florida

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