Accompanying Documents – Other CA Counties

Lassen

If the individual is being hospitalized at a psychiatric facility, copy all medical clearance information, 5150, progress note, EMTALA paperwork and disperse as follows:

  • Confidential envelope for the receiving facility to be given to the driver;
  • Copy for Lassen County Mental Health Medical Records;
  • Copy for Lassen County Mental Health nurse reviewer – who follows the case through discharge. Mental Health staff DO NOT WRITE IN BANNER LASSEN‘S CHART – EVEN IF ASKED. Instead will POLITELY OFFER A COPY OF PROGRESS NOTE.

Obtain from hospital staff the sealed envelope of documents to be delivered with the patient to the psychiatric facility.

Mono

Mammoth Hospital staff will prepare a jacket of transfer documents to be carried by ambulance personnel to the admitting psychiatric facility. The packet will contain copies of the medical records, the mental health consultation note, the 5150 form and advisement (original preferred; copy is legally equivalent), and any other admission materials required by the accepting facility. Additionally, the ambulance will receive a copy of the 5150 documents to enable their transfer.

Napa

Upon arrival, the transporting person and the Emergency Response Team staff member will consult regarding the individual in crisis.

For an involuntary hold, Law Enforcement staff will also provide Emergency Response Team staff with the completed 5150 form.

Yolo

Distribution of paperwork:

  • Accepting hospital: (Copies of the following forms are faxed to accepting psychiatric facility by Crisis staff as part of the referral process; originals are placed in sealed envelope by Emergency Room staff to accompany individual to the facility):
    • Original 5150 form with date and time (copy is legally equivalent);
    • Original Memorandum of Transfer with date and time;
    • Copies of all laboratory work, face sheet, Emergency Room cover sheet, and any pertinent written reports.
  • Ambulance: (Copies of the following documents are placed in a sealed envelope by Emergency Room staff)
    • authorizing transfer with diagnosis and doctor signature;
    • Copy of the 5150 form;
    • Copy of the Memorandum of Transfer;
    • Copy of the face sheet;
    • Copies of the remainder of the chart information.
  • ADMH: (Copies made by Crisis staff)
    • Copies of all above paperwork.
  • Hospital where the individual was originally evaluated: (Copies made by Emergency Room staff):
    • Copy of the 5150 form;
    • Copy of the Memorandum of Transfer (the pink copy of the triplicate form stays with the hospital chart).