/ AHCCCS Medical Policy Manual

AMPM Policy 320-Q, Exhibit 320-Q1,

Application for Voluntary Evaluation

(PursuanttoA.R.S.§36-522)

Theundersignedherebyrequestsamentalhealthevaluationtobeperformedbypsychiatrists,psychologists,andsocial workersat onthefollowingterms:

Regional Authority

Inpatient,Iagreetoremainasaninpatientintheaboveagencyforaperiodofnotmorethan72hours. Iunderstandthat,attheendofthatperiod,theagencymustreleasemeorfileforaPetitionforCourt-OrderedTreatment,inwhichcaseImaybehelduntilthecourtholdsahearing,whichshallbenolongerthansixdaysfromthedateoffilingthepetition,excludingweekendsandholidays. IfsuchaPetitionisfiled,Iwillhavetherighttorepresentationbyalawyer,andthecourtwillappointoneformeifIcannotaffordone.

Outpatient,Iagreetokeepallscheduledappointmentsrequiredforacompleteevaluation,tothebestofmyability. I understandthatifIfailtoappear,aPetitionforCourt-OrderedEvaluationorTreatmentmaybefiled,inwhichcaseImaybedetainedandrequiredtoundergoinvoluntaryevaluationandtreatment. IfsuchaPetitionisfiled,Iwillhavetherighttorepresentationbyalawyer,andthecourtwillappointoneformeifIcannotaffordone.

Iunderstandthatthephysician-patientprivilegedoesnotapply,andinformationIgiveduringthisevaluationmaybeusedincourtinacivilhearingforcourt-orderedtreatment.

IunderstandthatthisevaluationmayleadtoacourthearingtodetermineifIneedfurthertreatmentandthatsuchtreatment,oraninvestigationintotheneedforaguardianship,maybeorderedbyacourt.

IunderstandthatanapplicationformyexaminationhasbeenfiledandIchoosetobeevaluatedvoluntarilyratherthanbycourtorder.

Iunderstandthatmyevaluationmusttakeplacewithinfivedaysofmyapplication.

IunderstandthatIhavearighttorequirethepersonwhohasappliedformyevaluationtopresentevidenceoftheneedforsuchevaluationtoacourtoflawforapprovalordisapprovalandIwaivemyrighttorequirepriorcourtreviewoftheapplication.

IunderstandthatIhavearight,uponwrittenrequest,tobedischargedwithin24hoursofthatrequest(excludingweekendsandholidays)unlessthemedicaldirectoroftheevaluationagencyfilesapetitionforcourt-orderedevaluation.

PresentedBy:

SignatureofApplicant:

PrintedorTypedNameofApplicant:

Date:

Initial Effective Date: 7/01/2016