INSTRUCTIONS: MICHIGAN REPORT OF PHYSICIAN OR MENTAL HEALTH PROFESSIONAL (Form PC 630)
The form discussed in this article is filed by a Michigan physician or mental health professional to evaluate the ability of a person to care for themselves and make informed services as part of a probate case. This document can be obtained from the website maintained by the Michigan Courts system.
Michigan Report Of Physician Or Mental Health Professional PC 630 Step 1: Enter the file number where indicated.
Michigan Report Of Physician Or Mental Health Professional PC 630 Step 2: On the first blank line, enter the name of person being evaluated.
Michigan Report Of Physician Or Mental Health Professional PC 630 Step 3: On line 1, indicate with a check mark whether you are a physician or a mental health professional. If you have a specialty, enter it where indicated.
Michigan Report Of Physician Or Mental Health Professional PC 630 Step 4: On line 2, enter the date on which you last examined the individual.
Michigan Report Of Physician Or Mental Health Professional PC 630 Step 5: On line 3, enter the psychological or physical infirmities the individual suffers from.
Michigan Report Of Physician Or Mental Health Professional PC 630 Step 6: On line 4, describe the ways in which these infirmities interfere with the individual's ability to receive or evaluate information when making decisions.
Michigan Report Of Physician Or Mental Health Professional PC 630 Step 7: On line 5, list all medications the individual is receiving, the dosage of each medication and a description of the effects of each medication upon the individual's behavior.
Michigan Report Of Physician Or Mental Health Professional PC 630 Step 8: On line 6, indicate with a check mark all areas in which the individual is unable to make informed decisions.
Michigan Report Of Physician Or Mental Health Professional PC 630 Step 9: On line 7, enter the prognosis for improvement in the individual's conditions.
Michigan Report Of Physician Or Mental Health Professional PC 630 Step 10: Check the box on line 8 if you have attached further comments on a separate sheet.
Michigan Report Of Physician Or Mental Health Professional PC 630 Step 11: On the last five blank lines, enter the date, your signature, your typed or printed name, your street address, and your city, state, zip code and telephone number.
