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NC DMH 5-72-20A: Immediate Hospitalization Certificate

North Carolina commitment examiners attach DMH 5-72-20A to the first examination (DMH 5-72-19) when they find that a respondent needs immediate hospitalization to prevent harm to self or others. It is used in the emergency procedure, without a prior custody order. Under G.S. 122C-262(d), the sworn certificate itself serves as the custody order, and law enforcement or another authorized person transports the respondent to a 24-hour facility.

Who completes it

The commitment examiner who performed the first examination completes the certificate and checks a credential: MD/DO, eligible psychologist, PA, master's-level NP, LCSW, LCMHC, LMFT, or LCAS for substance abuse only. A notary completes the jurat, and the transporting officer completes the Return of Service on page 2.

Submitting and payment

How to submit it
The certificate travels with the respondent and the first examination to the 24-hour facility, and a copy goes to the clerk of court in the county of the receiving facility. If the clerk cannot get it within 24 hours, excluding weekends and holidays, the examiner also phones in the findings.

Good to know

  • The examiner checks whether the respondent is mentally ill and dangerous to self, to others, or both, and whether the respondent also has an intellectual disability.
  • The certificate must be sworn and subscribed before a notary public, with the notary's seal, before it can serve as a custody order.
  • DMH 5-72-20B is the same emergency certificate without the transport request and return of service; the current 20A revision is dated 8/2024.

Get the official form

Download the current version from the source each time; forms change without notice.

Supplement to Examination for Involuntary Commitment: Certificate to Support Immediate Hospitalization

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Does the NC emergency certificate need to be notarized?

Yes. The DMH 5-72-20A includes a jurat where the examiner swears to and subscribes the certificate before a notary public, who signs, prints their name, adds a commission expiration date and seals it. Because the certificate serves as the custody order, the notarization matters.

What is the difference between DMH 5-72-20A and 5-72-20B?

Both certify that a respondent requires immediate hospitalization to prevent harm. The 20A adds the transport request and a Return of Service page that the transporter completes with custody and delivery times; the 20B is the same certificate without the transport section. Both are used with the first examination form.