Get Mhcc 15 State Of Connecticut Department Of Mental Health And Addiction Form

The Mhcc 15 form is essential for securing transportation authorization for individuals receiving mental health and addiction services in Connecticut. This guide will provide a clear, step-by-step process for completing the form online, ensuring that you meet all necessary requirements.

Follow the steps to complete the Mhcc 15 form effectively

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by clearly printing or typing information in the identification section. This includes the patient’s name, address, and birthdate. Ensure accuracy as this information is crucial for identification.
3. Fill out the transportation section by indicating the type required (e.g., commercial invalid coach, ambulance). You must check the appropriate box to confirm the transport type authorized.
4. Provide details on the transportation provided, including the time dispatched and time arrived. Ensure that this information is clearly documented, as it supports the authorization.
5. Complete the reason for transportation by selecting the correct categories, such as 'psychologically disabled patient' or 'voluntary substance abuse treatment.' It is important to complete this section accurately.
6. In the certifications section, the examining physician must sign and provide their Connecticut medical license number. Also, the authorized treatment provider representative should sign, verifying that the patient requested transportation.
7. Fill out the receiving facility certification, ensuring the name of the patient and facility is clearly provided, along with the name of the ambulance company transporting the patient.
8. Finally, ensure the ambulance company certification is completed, which includes a signature from an authorized representative verifying payment attempts and liability determination.
9. After completing all required sections, you can save changes, download, print, or share the form as needed.

Complete your Mhcc 15 form online today to ensure timely transportation authorization.