Administrative Code Provisions | Ariz. Admin. Code ยง R9-21-508 Exhibit G | 2018
(Pursuant to A.R.S. § 36-541.01)
REGARDING: ___ (Full Name of Patient)
Pursuant to A.R.S. § 36-541.01, with respect to the above-named patient, a person who was ordered to undergo treatment for a mental disorder as a danger to others pursuant to A.R.S. § 36-540 by a court order of the Superior Court of ___ County, Case Number ___, or who was committed by an Arizona tribal court, which order of commitment was duly domesticated pursuant to A.R.S. §§ 12-1702 et seq., the undersigned ___ relative ___victim does hereby demand that the medical director of ___, the mental health treatment agency providing court-ordered treatment for said person, provide the undersigned with written notice of intention to release or discharge said person prior to the expiration of the period for treatment ordered by the Court, as provided for in A.R.S. § 36-541.01(D).
The undersigned person demanding notice hereby agrees to advise the treatment agency in writing, by certified mail, return receipt requested, of any change in the address to which notice is to be mailed.
___
Signature of Applicant
___
Printed or Typed Name of Applicant
___
Date
___
Address to Mail Notice
___
Telephone Number of Applicant
ADHS/BHS Form MH-127 (9/93)