Section 1 of 1 in this document

Quarterly Report - Monitoring Healthcare Provider

Participant's Name:

Monitoring Healthcare Provider's Name & Credentials:

Monitoring Healthcare Provider's Contact Information:

Indicate which quarter this report covers:

1st Quarter

2nd Quarter

3rd Quarter

4th Quarter

Appointment Date(s):

Current Diagnosis:

List all current medications and reason (prescribed by this medical provider only):

Has there been a change in the participant's diagnosis and/or treatment? If yes, please explain.

Does the current diagnosis affect the participant's ability to practice in the field they are licensed in? If yes, please explain.

Do you recommend any changes to the participant's treatment requirements, including the frequency of services, need for re-evaluation, work restrictions, etc.? If yes, please explain.

Is the participant complaint in treatment (willing participant, attends appointments as scheduled, demonstrates motivation to work toward goals, etc.) Please explain.

Does the participant have insight into their condition? Please explain.

To your knowledge, is the participant adherent with their IPHP contract?

Yes

Has the participant signed releases for you to communicate with their therapist and/or aftercare provider?

Yes

Have you communicated with the participant's therapist and/or aftercare provider this quarter? If yes, please explain.

SUBSTANCE USE CASES ONLY: Do you have any concerns about the participant's ability to travel outside of the U.S. or to a location where drug screen monitoring is not available during this next reporting quarter based on their status at the time of this report?

Yes

To your knowledge, has the participant experienced a return to use during this quarter?

Yes

What is your assessment of the participant's condition and prognosis?

Would you like IPHP staff to contact you?

Yes

Any further Comments, Questions or Concerns?

Your Signature:

First Name

Last Name

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