HomeMy WebLinkAbout09-04-08 OMMONWEALTH OF PENNSYLVANIA
NOTIFICATION OF MENTAL HEALTH COMMITMENT
The Pennsylvania Uniform Firearms Act, 18 PA. C.S. 6105(c)(4) specifies that it shall be unlawful for any person adjudicated as an incompetent or who
has been involuntarily committed to a mental institution for inpatient care and treatment under Section 302, 303, or 304 of the Menial Health Procedures
Act of July 9, 1979 (P.L.817, No. 143} to possess, use, manufactr~re, control, sell or transfer firearms. This would include adjudication of incapacity
pursuant to 20 Pa.C.S.A. 5501. Pursuant to the Pennsylvania Mental Health Procedures Act, Section 109, notifigtion shall be transmitted to tfie
Pennsylvania State Police by the judge, mental health review officer or county mental health and mental retardation administrator within SEVEN days of
the adjudication, commitment or treatment by first class mai{ to the Pennsylvania State Police, Attention: P1CS Unit, 1800 Elmerton Avenue,
Harrisburg, PA 17110. NOTE: The envelope shall be marked "CONFIDENTIAL."
Place an "X" on either Involuntary Commitment and indicate 302, 303, 304, or Adjudicated Incompetent
PRINT CLEARLY oR TYPE 362 303 304 OTHER:
INVOLUNTARY COMMITMENT ^ ^ ^ ^ ADJUDICATE1 D INCOMPETENT
DATE OF COMMITMENT OR ADJUDICATED INCOMPETENT ~~J~~I °~~~
COUNTY OF COMMITMENT Cumberland County
INDIVIDUAL INFORMATION -INDIVIDUAL INVOLUNTARILY COMMITTED OR ADJUDICATED INCOMPETENT
LAST NAME Bauerle
FIRST Margaret
MIDDLE E -
JR., ETC. MAIDEN NAME
DATE OF BIRTH 0 8/ 1 3/ 1 91 0
ALIAS
SOCIAL SECURITY NUMBER 1 6 5- 0 3- 4 31 5
S~ Female RACE Caucasiani-IEIGHT WEIGHT
HAIR EYES
ADDRESS Church of God Home, Iric., 801 North Hanover Street
Carlisle, PA 17103
302 Commitment Requires Physician's Certification
Physician Certifying Necessity of Involuntary Commitment
(Required in accordance with Section 6105(c)(4) of the Uniform Firearms Act)
Please Print Name and Provide Signature
Hospital !Facility Providing Treatment /Address
NOTIFICATION BY (Please print name, address, area code, and phone number of agency or county court.}
MHlMR Administrator /Review Officer Cumberland County Clerk of Orphans' Phone (717) 240-6345
Court
Address One Courthouse Square, Carlisle, PA 17013
303 and 304 Commitment -Requires Judge's name authorizing commitment, case number & order date
Judge ECIt/JQ~~( [, Cu~clo
Court Case Number o2 ~ - Ogy v ~~ ~ Date of Court Order g.l ~ 3~°7OUg
SIGNATURE OF NOTIFYING OFFICIAL Date (/'/%J ~2J ,t~7~'`(~~y~t/~~J
g
NOTIFICATION OF PHYSICIAN'S DETERMINATION THAT NO SEVERE MENTAL DISABILITY
EXISTS
The physician shall provide signed confirmation of the lack of severe mental disability following the initial examination under Section 302(b) of the Mental
Health Procedures Act and pursuant to the Pennsylvania Uniform Firearms Act, Section 6111.1 (g}(3). Notice shat{ be transmitted by physiaan to the
Pennsylvania State Police through the county mental health and mental retardation administrator or mental health review officer.
Name of Physician (Please print.)
Signature of Physician Date