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Notice Of Hospitalization And Certification Of Service PCM 211 - Michigan
| Notice Of Hospitalization And Certification Of Service Form. This is a Michigan form and can be used in Mental Health Statewide . |
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Approved, SCAO OSM CODE: NO/CSP STATE OF MICHIGAN FILE NO. PROBATE COURT NOTICE OF HOSPITALIZATION AND COUNTY CERTIFICATION OF SERVICE CIRCUIT COURT - FAMILY DIVISION In the matter of NOTICE TO THE PROBATE COURT: Attached is an application for hospitalization and two clinical certificates. You are notified that: 1. The above named individual was hospitalized on at m. Date Time 2. The clinical certificate of psychiatrist required for hospitalization was completed on at m. Date Time CERTIFICATION OF SERVICE ON PATIENT 3. I certify that on the dates and times indicated a copy of each of the following documents was given to the above individual. a. Application/Petition m. Date Time Signature b. Statement explaining individuals rights Date Time m. Signature c. Clinical certificate of psychiatrist Date Time m. Signature d. Clinical certificate of licensed psychologist/ m. physician/psychiatrist Date Time Signature e. Notice of hearing m. Date Time Signature CERTIFICATION OF SERVICE ON OTHERS 4. I certify that copies of the application/petition, two clinical certificates, statement explaining rights, and notice of hearing were mail given by personal service on m. to Date and time Individuals guardian nearest relative mail and by personal service on m. to . Date and time Individuals attorney 5. I further certify that the individual was asked if s/he desired that other persons be sent copies of these documents, and the individual designated . mail. a. Copies were given them on Date by personal service. b. Service was not made because the person(s) could not be located. Date Signature Do not write below this line - For court use only MCL 330.1430; MSA 14.800(430), MCL 330.1431; MSA 14.800(431), MCL 330.1448; MSA 14.800(448), MCL 330.1449; MSA 14.800(449) PCM 211 (9/97) NOTICE OF HOSPITALIZATION AND CERTIFICATION OF SERVICE
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