INTENT TO TERMINATE mental health treatment
Michigan Department of Health and Human Services
Authority: Section 330.4019 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 mental health
treatment of	, effective	(a.m./p.m.) on
(date).
Signed
Recipient Guardian Patient Advocate
Signature of Witness	Date	Time
I understand that, except if rescinded, a formal voluntary patient over 18 years of age shall not be kept in the hospital/provided mental health treatment for more than 3 days, excluding Sundays and holidays, after receipt by the hospital of a written notice of intent to terminate mental health treatment. Seventy-two (72) hours from this time and date (excluding Sundays and Holidays) will be:
Date	Time
a.m. p.m.
Recipient: Once the written notice of termination of mental health treatment is given to the hospital, and if the notice is not withdrawn, recipient attending psychiatrist will begin the evaluation of your need for involuntary hospitalization/mental health treatment within 24 hours of the written notice. If he/she determines that you are dangerous to yourself or others, or that you are unable to attend to my basic personal needs such as food, clothing and shelter, that are necessary to avoid serious harm in the near future, the doctor and the hospital, as required by law, will file an application for involuntary hospitalization/mental health treatment.
CONTINUATION OF HOSPITALIZATION/MENTAL HEALTH TREATMENT
(Revocation of Intent to Terminate Mental Health Treatment)
I	hereby rescind the request to terminate mental health
treatment 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 300.1419 Administrative Code, Rule 330.4077