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Forms and Documents

The following forms and documents are available to be downloaded.

VRP Enrollment Paperwork

• VRP's Terms and Conditions for Participation (PDF)

• VRP's Participation Cooperation Form (PDF)

• VRP Demographics & Medical History Questionnaire (PDF)
• VRP Personal Data Sheet (PDF)

DMU Enrollment Paperwork

• DMU Personal Data Sheet (PDF)

Drug Testing 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)

• Physicians' Health Program Release (PDF)

• PA Nurse Peer Assistance Program Release (PDF)

Support Group

• Support Group Attendance Record (PDF)

Content Editor

PHMP Resources

Voluntary Recovery Program (VRP)

VRP Participating Licensing Boards

VRP Eligibility Requirements

VRP Terms and Conditions for Participation (PDF)

Disciplinary Monitoring Unit (DMU)

How to Report a Licensee

Forms and Documents

Contact

Mailing Address:

Professional Health Monitoring Program
P.O. Box 10569,
Harrisburg, PA 17105

Phone:
(800) 554-3428 or
(717) 783-4857
Fax: (717) 772-1950

Email:
RA-STPHMP@PA.GOV