The following shall be submitted when initiating the IVA of an individual: An application for IVA completed under the provisions of Regulation .03 of this chapter; and A certificate completed by: Two physicians; One physician and one psychologist; or One physician and one psychiatric nurse practitioner. The Secretary shall provide the certificate that includes the following: The statutory authority for the certificate; The form number (MDH2) and revision date; A list of the appropriate documentation that shall be attached to one of the certificates; A statement that the certificate may not be used for the IVA of an individual if the examination on which the certificate is based was done: More than 1 week before the certificate is signed; or More than 30 days before the inpatient facility or the Veteran’s Administration hospital receives the application for admission; A list of the State inpatient facilities and the catchment areas from which each facility accepts referrals; Spaces for the following information: The name, address, and telephone number of the certifying physician, psychologist, or psychiatric nurse practitioner; The name, address, identifying data, and the next of kin of the individual for whom the certificate is made; The date that the physician, psychologist, or psychiatric nurse practitioner examined the individual; A diagnosis of a mental disorder of the individual; An opinion that: The individual needs inpatient care or treatment; and Admission to an inpatient facility is needed for the protection of the individual or another; and The individual's: Current medications; and Emergency medications; A statement of whether the individual who completes the certificate is a physician, psychologist, or psychiatric nurse practitioner; The statement that the physician, psychologist, or psychiatric nurse practitioner: Has no financial interest, through ownership or compensation, in a proprietary inpatient facility, and admission to that proprietary inpatient facility is sought for the individual whose status is being certified; and Is not related, by blood or marriage, to the individual or to the applicant; and Space for the signature of the physician, psychologist, or psychiatric nurse practitioner and for the date and time the certificate is signed. To complete a certificate for IVA, a physician, psychologist, or psychiatric nurse practitioner shall: Personally examine an individual for whom an application for IVA has been completed under the provisions of Regulation .03 of this chapter; Completely fill out the form described under §B of this regulation; Sign, date, and time the certificate not later than 1 week following the examination required under §C(1) of this regulation; and Attach to one of the certificates for IVA copies of any available current medical reports or records that support the individual's need for involuntary care or treatment in an inpatient facility, with reports including at a minimum: The diagnosis of mental disorder, current symptoms, and psychiatric history; A summary of the medical history, including documentation of medical clearance; An explanation of why the individual meets the following requirements for IVA: The individual has a mental disorder; The individual needs inpatient care or treatment; The individual presents a danger to the life or safety of the individual or of others; The individual is unable or unwilling to be admitted voluntarily; There is no available, less restrictive form of intervention that is consistent with the welfare and safety of the individual; and Unless the individual is an emergency evaluee, if the individual is 65 years old or older and is being referred for admission to a State inpatient facility or a VA hospital, a GES team has determined that there is no available, less restrictive form of care or treatment that is adequate for the needs of the individual; If the individual is an emergency evaluee, a copy of the petition for emergency evaluation; and If the individual is discharged from an inpatient facility after appropriate staff at the inpatient facility have completed application and certificates for IVA to initiate the direct confinement of the individual in another inpatient facility: The information outlined in §C(4)(a) — (d) of this regulation; The discharge summary; A copy of the individual's most recent ITP completed in accordance with Health-General Article, §10-706, Annotated Code of Maryland, and COMAR 10.21.03; and Copies of all voluntary and involuntary admissions documents relating to the current admission at the inpatient facility from which the individual is discharged. An inpatient facility may not use for the admission of an individual a certificate that: Is based on an examination that was done: More than 1 week before the certificate is signed; or More than 30 days before the inpatient facility receives the application for admission; or Was previously used in connection with the taking into confinement on observation status an individual who subsequently was admitted to or released or discharged from an inpatient facility.