Common Contracts
3 similar Consent to Services Enrollment Agreement contracts
Consent to Services Enrollment AgreementConsent to Services Enrollment Agreement • February 8th, 2022
I, , am a licensee of the (“Board/Commission”). I acknowledge that I have been referred by my Board/Commission to the Delaware Professionals’ Health Monitoring Program (“Program”) provided by Uprise Health. I understand that I will be required to have a third-party evaluation. I understand that I will be required to follow any care requirements recommended by the third-party evaluator and the Program. I understand that I need to cease work until I have completed the third-party evaluation and recommendations have been made regarding my return to work.
Consent to Services Enrollment AgreementConsent to Services Enrollment Agreement • September 9th, 2020
I, , am a licensee of the (“Board”). I acknowledge that I have been referred to IBH Solutions, also known as the Delaware Professionals’ Health Monitoring Program (“Program”) by my Board/Commission. I understand that I will be required to have a third-party evaluation. I understand that I will be required to follow any care requirements recommended by the third-party evaluator and the Program. I understand that I need to cease work until I have completed the third-party evaluation and recommendations have been made regarding my return to work.
Consent to Services Enrollment AgreementConsent to Services Enrollment Agreement • May 18th, 2020
I, , am a licensee of the (“Board/Commission”). I acknowledge that I have self-referred to IBH Solutions, LLC, also known as the Delaware Professionals’ Health Monitoring Program (“Program”). I understand that I will be required to have a third-party evaluation. I understand that I will be required to follow any care requirements recommended by the third-party evaluator and the Program. I understand that I need to cease work until I have completed the third-party evaluation and recommendations have been made regarding my return to work.
