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Pennsylvania Department of State
Menu
Business & Charities
Business & Charities
Business
Charities
Professional Licensing
Professional Licensing
Board Contacts
Boards & Commissions
File a Complaint
Licensing Services
Verify a Professional
Other Services
Notaries
Voting & Elections
Voting & Elections
Candidates & Committees
Special Elections
Voters
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2018 HAVA Election Security Grant
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Pennsylvania Department of State
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Professional Licensing
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Other Services
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Professional Health Monitoring Programs
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Forms and Documents
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Forms and Documents
The following forms and documents are available to be downloaded.
Enrollment materials
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Terms and Conditions for Participation in the Voluntary Recovery Program (PDF)
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Voluntary Recovery Program's Participation Cooperation Form (PDF)
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Personal Data Sheet (PDF)
Drug screening information
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Drug Testing General Information (PDF)
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Travel Procedures (PDF)
Consents for Release of Information
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Treatment provider release (PDF)
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Employer release (PDF)
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PA Board Counsel release (PDF)
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Attorney release (PDF)
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Insurance company release (PDF)
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Other state board release (PDF)
Support Group
•
Support Group Attendance Record (PDF)
PHMP Resources
Voluntary Recovery Program
How to Report a Licensee
VRP Participating Licensing Boards
VRP Eligibility Requirements
VRP Terms and Conditions for Participation (PDF)
Disciplinary Monitoring Unit
Contact
Mailing Address:
Professional Health Monitoring Program P.O. Box 10569, Harrisburg, PA 17105-0569
Phone: 800-554-3428 or 717-783-4857 Fax: 717-772-1950
Email:
RA-STPHMP@PA.GOV