FORM 1013 – CERTIFICATE AUTHORIZING ... - djj.state.ga.us

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Georgia Department of Behavioral Health & Developmental Disabilities (DBHDD) Identification FORM 1013 CERTIFICATE AUTHORIZING TRANSPORT TO EMERGENCY RECEIVING FACILITY & REPORT of transportation (Mental Health) ________________________________________ ________________________________________ ___________________ Form 1013 CERTIFICATE AUTHORIZING Transport to Emergency Receiving Facility & Report of transportation Mental Health DBHDD By Authority of 37-3-41, 37-3-42 & 37-3 -101 -Form Last Revised ; Effective Page 1 of 2 STATE OF GEORGIA, COUNTY OF___________________________ DATE ________________ This is to certify that I have personally examined ________________________________________ _________ on _________________________, 20____ at ______m, which was within the preceding 48 hours of the signing of this CERTIFICATE .

Form 1013 – Certificate Authorizing Transport to Emergency Receiving Facility & Report of Transportation – Mental Health DBHDD By Authority of O.C.G.A. § 37-3-41, 37-3-42 & 37-3-101 -Form Last Revised 03.20.2012; Effective 03.31.2012- Page 2 of 2

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