Pennsylvania Department of State > Professional Licensing > Other Services > Professional Health Monitoring Programs > Forms and Documents

Forms and Documents

The following forms and documents are available to be downloaded.

Enrollment materials

• Terms and Conditions for Participation in the Voluntary Recovery Program (PDF)

• Voluntary Recovery Program's Participation Cooperation Form (PDF)

• Personal Data Sheet (PDF)

Drug screening information

• Drug Testing General Information (PDF)

• Travel Procedures (PDF)

Consents for Release of Information

• Treatment provider release (PDF)

• Employer release (PDF)

• PA Board Counsel release (PDF)

• Attorney release (PDF)

• Insurance company release (PDF)

• 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