NOTICE OF INTENT TO TERMINATE HOSPITALIZATION OF A MINOR
Michigan Department of Health and Human Services
Authority: Section 330.4620 of Public Act 258 of 1974 as amended. Information contained on this form is covered by Federal and State privacy and confidentiality laws. THIS LEGAL FORM IS APPROVED BY THE MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES AND CANNOT BE ALTERED OR ABRIDGED WITHOUT FORMAL APPROVAL.
I	hereby give notice of intent to terminate the hospitalization
of	, effective	(a.m./p.m.) on
(date).
Signed
Relationship to Person Requiring Treatment
Minor over 14	Parent
Legal Guardian	Person in loco parentis (explain)
Signature of Witness	Date	Time
I understand that, except if rescinded, a minor hospitalized under this chapter shall not be kept in the hospital more than 3 days, excluding Sundays and holidays, after receipt by the hospital of a written notice of intent to terminate the hospitalization of the minor executed by the minor’s parent, guardian, or person in loco parentis or by the minor if the minor is 14 years of age or older and was admitted to the hospital upon his or her own request. Seventy-two (72) hours from this time and date (excluding Sundays and Holidays) will be:
Date	Time
a.m. p.m.
I understand that, with 24 hours of the time of this notice, the attending psychiatrist will begin an evaluation of the minor’s need for involuntary hospitalization. If it is determined that the minor is dangerous to self or others, the doctor and the hospital, as required by law, will file an application for involuntary hospitalization. I also understand that I may withdraw this request by completing the section indicated below.
CONTINUATION OF HOSPITALIZATION
(Revocation of Intent to Terminate Hospitalization)
I	hereby rescind the request to terminate the hospitalization
effective	(a.m./p.m.) on	(date).
Signature	Date
The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.
AUTHORITY: PA 258 of 1974, as amended 1498(o) Administrative Code, Rule 330.4620