§ 5100.23. Written application, petitions, statements and certifications.

 (a)  Written application, petitions, statements and certifications required under this chapter shall be made upon forms issued or approved by the Department.

 (b)  The forms listed in §  5100.41 (relating to forms) have been issued by the Department, and their use is mandated. No substitute for such forms is permitted without prior written authorization of the Deputy Secretary of Mental Health.

 (c)  Other forms required under this chapter may be developed by the administrator or the facility, but are subject to the approval of the Department.

 (d)  Unsworn falsification—all statements written under all applications, petitions and certifications required under the act on Departmentally issued or approved forms MH 781, 783, 784, 785, 786 and 787, shall contain the following notice—old forms may be utilized until the supply is exhausted:

  ANY PERSON WHO KNOWINGLY PROVIDES ANY FALSE INFORMATION WHEN COMPLETING THIS FORM MAY BE SUBJECT TO PROSECUTION.

 (e)  When a person is admitted for voluntary treatment and only when no part of his treatment is provided with public funds, the new voluntary admission Form MH-788 may be used. This form will be identical to Form MH-781 with the exception that the notice concerning the penalty for giving false information will be deleted. Until form MH-788 is printed and distributed, existing Form MH-781 may be utilized for this group of persons. Each facility may make the necessary deletion on Form MH-781 to conform with section 110(c) of the act (50 P. S. §  7110(c)).

 (f)  Submission to county administrator:

   (1)  Except as set forth in paragraphs (2)—(5), Forms MH 781, 783, 784, 785, 786 and 787, shall be provided to the administrator under section 110 of the act (50 P. S. §  7110).

   (2)  No Form MH-788 need be provided to the administrator on behalf of a patient admitted for voluntary treatment when reimbursement for treatment provided the patient will not include public monies. This shall not affect in any way the applicability to such patients of the rights and procedures afforded voluntary patients by the act and this chapter. For admission to a State facility forms must be provided to the administrator.

   (3)  The administrator shall review all applications, petitions, statements and certifications provided to the administrator’s office to determine whether the services needed are available and to assure a continuity of care.

   (4)  The administrator may designate a place other than his office for filing of the forms mentioned in this section.

   (5)  Mental health facilities shall file such statistical reports of activities and services required by the act and the Mental Health and Mental Retardation Act of 1966 as the Department from time to time may require, so long as the data does not identify individual patients.



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