936                                 Laws of Maryland                         Ch. 407

plication of any person having a legitimate interest in the welfare
of the proposed patient. No liability, either civil or criminal, shall
attach to any such applicant who makes the application in good
faith and with reasonable grounds.

(c)  Each such application for admission to a facility shall:

(1)   be in writing and dated;

(2)  be in such form as may be required by the Department; or
in respect to Veterans' Administration Hospitals, meets the require-
ments of that administration;

(3) contain a description of the relationship of the applicant to
the prospective patient;

(4) be signed by the applicant, and

(5)  be accompanied by the certificates of two physicians that the
prospective patient has a mental disorder, and for his protection or
others, needs inpatient care or treatment.

(6)  It may contain such additional information as the Depart-
ment may require.

(d)   (1) Each physician's certificate shall be in substantially the
following form:

PHYSICIANS CERTIFICATE TO ACCOMPANY
APPLICATION FOR INVOLUNTARY ADMISSION

Patient's Name......................................................................................................................................._

At the time of my examination, the above named patient showed
the following symptoms:

Physical (Illness, Injury, Deformity).................................................................................

Mental (History and Mental Status)

I hereby certify that on................................................, 19............, I, a graduate

of................................................Medical College and licensed to practice in the

State of Maryland, personally examined the above named patient
and believe that he has a mental disorder and that the disorder is
of a character which, in my opinion, requires that the patient be
placed in a facility for the treatment of the mentally disordered. I
am not related by blood or marriage to the patient, nor do I have
any financial interest in the facility in which it is proposed to place
the patient. I further certify that this certificate is signed and made
within one week of the examination of the patient.

Signed:................................................................................................ Date:....................................

(2) No certificate shall be used for purposes of admission if based
on an examination made more than 30 days prior to receipt of the