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Structure

The Michigan PC 630 form plays a crucial role in the legal process concerning individuals who may be unable to make informed decisions due to physical or psychological conditions. This form is primarily used by licensed physicians or mental health professionals to provide a detailed report on an alleged incapacitated individual. It requires the examiner to outline their specialty, the date of the last examination, and any relevant medical records that indicate the individual's health status. The form also delves into specific physical or psychological infirmities that may hinder the individual’s ability to process information and make decisions. Additionally, it asks for a list of medications the individual is taking, including dosages and their behavioral effects. Crucially, the form identifies the areas in which the individual may struggle to make informed choices, such as living arrangements, financial matters, and medical treatment decisions. The physician or mental health professional is also tasked with providing a prognosis for the individual’s condition and recommending a rehabilitation plan. Overall, the Michigan PC 630 form serves as a vital tool in assessing an individual’s capacity, ensuring that their rights and well-being are protected within the legal framework.

Form Example

Approved, SCAO

JISCODE:ROP/ROM

STATEOFMICHIGAN PROBATECOURT COUNTYOF

REPORTOFPHYSICIAN

ORMENTALHEALTHPROFESSIONAL

FILE NO.

In the matter of

1. I am a licensed

physician.

, alleged incapacitated individual

mental health professional. My speciality is

if any

2.I last examined the individual on

3.Basedonthatexaminationandher/hismedicalrecord,theindividualsuffersfromthefollowingphysicalorpsychologicalinfirmities:

4. These infirmities interfere in the following ways with the individual's ability to receive or evaluate information in making decisions:

5.The following is a list of all medications the individual is receiving, the dosage of each medication, and a description of the effects ofeachmedicationupontheindividual'sbehavior:

6.

I believe the individual, due to these described conditions, is not presently able to make informed decisions in the following areas:

 

check all that apply

determiningwheretolive.

handlingpersonalfinancialaffairs.

 

 

consentingtosupportiveservices.

authorizing or refusing medical treatment.

7.

The prognosis for improvement in the individual's conditions is

 

.

My recommendation for the most appropriate rehabilitation plan is attached.

8. Further comments are attached on a separate sheet.

Date

 

 

 

 

 

 

Signature

Address

 

 

 

 

 

Name (type or print)

City, state, zip

Telephone no.

USE NOTE: If this form is being filed in the circuit court family division, please enter the court name and county in the upper left-hand corner of the form.

Do not write below this line - For court use only

PC 630 (9/11) REPORT OF PHYSICIAN OR MENTAL HEALTH PROFESSIONAL

MCL 700.5304, MCR 5.405
▼ Michigan Pc 630 PDF Form

Document Specs

Fact Name Details
Purpose of the Form The Michigan PC 630 form is designed to provide a report from a physician or mental health professional regarding an individual's capacity to make informed decisions.
Governing Laws This form is governed by the Michigan Compiled Laws (MCL) 700.5304 and the Michigan Court Rules (MCR) 5.405, which outline the legal framework for assessing incapacity.
Required Information Physicians must include details about the individual's medical history, current medications, and the effects of those medications on decision-making abilities.
Signature Requirement The form must be signed by the licensed physician or mental health professional who conducted the examination, ensuring accountability and authenticity.
Prognosis and Recommendations Physicians are required to provide a prognosis for the individual's condition and recommend an appropriate rehabilitation plan, which may be attached as a separate document.
Filing Instructions If this form is filed in the circuit court family division, it is essential to include the court name and county in the designated area at the top of the form.
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