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Fill and Sign the Form Mc 415 Download Fillable PDF Notice of Voluntary

Fill and Sign the Form Mc 415 Download Fillable PDF Notice of Voluntary

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INSTRUCTIONS FOR EVALUATION FACILITY: This form shall be filed with the court immediately upon the respondent’s voluntary admission. MC -415 ( 8/18 )(cs) AS 47.30.725(b) NOTICE OF VOLUNTARY ADMISSION IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT In the Matter of the Necessity ) for the Hospitalization of: ) ) ) ) Case No. , ) Respondent. ) Date of Birth: ) NOTICE OF VOLUNTARY ) ADMISSION To: Superior Court at , Alaska. The court ordered that the respondent be h ospitalized for evaluation at one of the facilities below. Pursuant to that order, the res pondent w a s de l i v e r e d to th e following facility on : Alas ka Ps ych iatric Institute Peace Health Ketch ikan Medical Center Bartlett Regional Hos pital Yukon-Kuskokwim Delta Reg. Hos pital Fairbanks Memo rial Hospital The r espondent voluntarily admitted to this facility on , at am pm. Date Signature Print Name and Title Phone Number E-mail Address I certify that on , a copy of this notice was provided to: respondent parent/guardian PDA AGO OPA (only if respondent is a minor) By Clerk:

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