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Notification Of Mental Health Commitment - Pennsylvania

Notification Of Mental Health Commitment Form. This is a Pennsylvania form and can be used in Orphans Court York Local County .
 Fillable pdf Last Modified 1/16/2007
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SP 4-131(6-98) COMMONWEALTH OF PENNSYLVANIA NOTIFICATION OF MENTAL HEALTH COMMITMENT The Uniform Firearms Act, 18 PA. C. S. 6105 (c)(4) specifies that it shall be unlawful for any person adjudicated as an incompetent or who has been involuntarily committed to a mental institution for inpatient care and treatment under Section 302, 303, or 304 of the Mental Health Procedures Act of July 9, 1976 (P. L. 817, No. 143) to process, use, manufacture, control, sell or transfer firearms. This would include adjudication of incapacity pursuant to 20 Pa. C. S. A. ยง5501. Pursuant to the Pennsylvania Mental Health Procedures Act, Section 109, notification shall be transmitted to the Pennsylvania State Police by the Judge, mental health review officer or county mental health and mental retardation administrator within SEVEN days of the adjudication, commitment or treatment by first class mail to the Pennsylvania State Police, Attention: Firearm Unit, 1800 Elmerton Avenue, Harrisburg, PA 17110. NOTE: The envelope shall be marked "CONFIDENTIAL." Place an "X" on either Involuntary Commitment or Adjudicated Incompetent INVOLUNTARY COMMITMENT _______ ADJUDICATED INCOMPETENT _______ Date of Involuntary Commitment or Adjudicated Incompetent _________________ INDIVIDUAL INFORMATION (INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATED INCOMPETENT) LAST NAME_________________________________ FIRST_________________________________ MIDDLE __________________________ JR., ETC. _______________ MAIDEN NAME __________________________________ ALIAS _______________________________________ DATE OF BIRTH ________________________________ SOCIAL SECURITY NUMBER _____________________________________________ SEX ___________ RACE _____________ HEIGHT ____________ WEIGHT _____________ HAIR _____________ EYES __________ ADDRESS ______________________________________________________________________________________________________________ NOTIFICATION BY (Please print name, address, area code, and phone number of agency or county court.) County Submitting Notification __________________________________________________________________________________ County Mental Health and Mental Retardation Administrator __________________________________________________________ ____________________________________________________________________________________________________________ County Mental Health Review Officer ____________________________________________________________________________ ____________________________________________________________________________________________________________ Physician Certifying Necessity of Involuntary Commitment ___________________________________________________________ (Required in accordance with Section 6105 (c)(4) of the Uniform Firearms Act) Hospital / Facility Providing Treatment / Address ___________________________________________________________________ Judge_______________________________________________________________________________________________________ ____________________________________________________________________________________________________________ SIGNATURE OF NOTIFYING OFFICIAL _______________________________________________ DATE __________________ Court Case Number __________________________________________________ Date of Court Order _______________________ *************************************************************************************************************************************** NOTIFICATION OF PHYSICIAN'S DETERMINATION THAT NO SEVERE MENTAL DISABILITY EXISTS The physician shall provide signed confirmation of the determination of the lack of severe mental disability following the initial examination under Section 302(b) of the Mental Health Procedures Act and pursuant to the Uniform Firearms Act, Section 6111.1 (g)(3). Notice shall be transmitted by the physician to the Pennsylvania State Police through the county mental health and mental retardation administrator or mental health review officer. Name of Physician (Please Print) _______________________________________________________________________ Signature of Physician ________________________________________________________ Date __________________ American LegalNet, Inc. www.FormsWorkflow.com
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