The Commonwealth of Massachusetts
           Executive Office of Health and Human Services
                      One Ashburton Place, Room 1109
                        Boston, Massachusetts  02108

Tel: (617) 727-7600
Fax: (617) 727-1396
Fax: (617) 727-4446
Fax: (617) 727-5134
TDD: (617) 727-0014

                         CIRCULAR LETTER:  DHCQ 4-00-400

ARGEO PAUL CELLUCCI
GOVERNOR
JANE SWIFT
LIEUTENANT GOVERNOR
WILLIAM D. O’LEARY
SECRETARY	

TO:            Administrators/Long Term Care Facilities
                   Directors/ Massachusetts Ambulance Companies

FROM:       Paul  I. Dreyer, Director                                      
                    Massachusetts Department of Public Health   
                    Division of Health Care Quality     

                    Louise Goyette, Director
                    Massachusetts Department of Public Health
                    Office of Emergency Medical Services
                   
                    Michael Weeks, Director of Licensing
                    Massachusetts Department of Mental Health
                    Clinical and Professional Services

DATE:         April 4, 2000

SUBJECT:  Unauthorized use of DMH form AA-1, “Application for and Authorization of 
                     Temporary  Involuntary Hospitalization,” pursuant to M.G.L. Ch. 123,  s. 12.

It has come to the attention of the Departments of  Mental Health and Public Health, that some patients are being transported, by ambulance,  to Long Term Care Facilities through the mechanism of a signed of DMH form AA-1, “Application for and Authorization of Temporary Involuntary Hospitalization,” commonly referred to as a “Section 12” form or ”pink paper”. 

This letter is to advise LTCFs and ambulance companies that use of this form for the purpose of transporting individuals to LTCFs is not permitted. Ambulance services should consult with their region for guidance on point of entry, should they be confronted with this situation. 
If you have any questions on this matter, please call:

For DHCQ: Kathleen Coyle, Assistant Director, at (617)753-8106.

For OEMS: Abdullah Rehayem, Supervisor/Ambulance Licensing Program at (617) 284-8300.

For DMH: Michael Weeks, Director/Licensing Division, Clinical and Professional Services at (617) 626-8120.