Notice Of Hospitalization And Certification Of Service {PCM 211}

Approved, SCAO PCS CODE: NO/CSP TCS CODE: NO/CSP STATE OF MICHIGAN PROBATE COURT COUNTY OF In the matter of NOTICE OF HOSPITALIZATION AND CERTIFICATE OF SERVICE FILE NO. First, middle, and last name NOTICE TO THE PROBATE COURT: Attached is a petition for hospitalization and two clinical certificates. You are notified that 1. The individual named above was hospitalized on Date at Time at Name of hospital Date . at Time 2. The clinical certificate of the psychiatrist that is required for hospitalization was completed on CERTIFICATE OF SERVICE ON PATIENT . 3. I certify that on the dates and times indicated a copy of each of the following documents was given to the individual named above. a. Petition b. Statement explaining individual's rights c. Clinical certificate of psychiatrist d. Clinical certificate of licensed psychologist/physician/psychiatrist e. Notice of hearing Date Date Date Time Time Time Signature Signature Signature Date Date Time Time Signature Signature CERTIFICATE OF SERVICE ON OTHERS 4. I certify that copies of the petition, two clinical certificates, statement explaining rights, and notice of hearing were served by first-class mail and by first-class mail personally personally on on Date and time Date and time on on Individual's guardian nearest relative Individual's attorney . 5. I further certify that the individual was asked whether to serve other persons with copies of the above documents. a. Name was designated. Copies were served by first-class mail personally on Date Copies could not be served. b. Name . was designated. Copies were served by first-class mail personally on Date Copies could not be served. Date . Signature Do not write below this line - For court use only American LegalNet, Inc. www.FormsWorkFlow.com PCM 211 (9/16) NOTICE OF HOSPITALIZATION AND CERTIFICATE OF SERVICE MCL 330.1430, MCL 330.1431, MCL 330.1448, MCL 330.1449