I have been informed of the meaning and content of this consent form and understand that my consent includes verbal, written, and electronic communications between the parties named herein. I also understand my consent may include the reproduction, transference, loan, and investigation of documents and information pertinent to only my individual drug testing and compliance requirements.
Name *
PIN # *
I hereby authorize release of only information regarding my impairment that enables
and/or Partnership for Professional Wellness and their agents to appropriately assist me in providing evidence-based validation of my ability to practice.
1 STATE LICENSING BOARD Required
Phone *
Name of Agency *
Address *
YOU MUST COMPLETE SECTION 1.
2 Additional Entity
Name
Phone
Agency
Address
3 Additional Entity
Participant’s initials signify approval. Initial all items.
to provide accurate and efficient information and documents to ensure appropriate advocacy for me.
to allow adequate and necessary information to adjudge my ability to return to practice and/or work safely.
to provide for the health, safety, and welfare of the public against unsafe practitioners.
for utilization by the appropriate regulating board for discipline of license(s).
Payment of drug testing fees is a compliance requirement. All payments in default will be reported to your licensing Board as well as the Board listed above.
This consent is subject to revocation at any time except to the extent that Partnership for Professional Wellness and their agents and/or the above-named person has taken action in reliance upon it.
Digital Signature *
Please sign inside the box using your mouse, trackpad, or finger.
Participant Name *
Date *
PARTICIPANT IS NOT ELIGIBLE FOR PARTICIPATION IN THIS PROGRAM IF THIS FORM IS NOT SIGNED AND INITIALED WHERE INDICATED.
