MCN’s customizable template, Request for Voluntary Admission to the Partial Hospitalization Program and Authorization for Treatment Form, is taken from our Behavioral Health Partial Hospitalization Program Policy and Procedure Manual. MCN Healthcare’s proven policy and procedure templates, competencies and compliance tools have assisted more than 20,000 health care organizations worldwide meet their regulatory compliance goals.

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Here is some sample content from Request for Voluntary Admission to the Partial Hospitalization Program and Authorization for Treatment Form:

	REQUEST FOR VOLUNTARY ADMISSION TO THE PARTIAL HOSPITALIZATION PROGRAM AND AUTHORIZATION FOR TREATMENT The undersigned requests admission to the Partial Hospitalization Program at and consents to such care and treatment as is ordered by the undersigned's attending physician or his/her designee. If my request is granted, I agree to conform to all the rules and regulations of the program. If I wish to leave the program, I will give notice of my desire to leave to a program staff member and will complete all normal hospitalization departure procedures. In the event that I leave the program...
Second excerpt:
	...person and my possessions, which may be made by any qualified employee legally authorized to make such inspection and with my consent. I release the facility and its employees from any liability or other responsibility for the consequences of such an inspection. I understand that it may be the desire of my attending physician to permit that maximum amount of freedom of action commensurate with my condition as an important factor in my treatment program. This freedom of action may lead to...