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 • August 3rd, 2020
(“Board”). I acknowledge that I have self-referred to Integrated Behavioral Health, LLC, Health Professionals’ Services Program (“Program”) and previous to this date and pursuant to my Provisional Enrollment Agreement, I have been diagnosed by a Board-approved independent third-party evaluator as having a:
Consent to Services Enrollment Agreement Self ReferredConsent to Services Enrollment Agreement • December 22nd, 2010
And that I have been provided with treatment options by my Board-approved independent third party evaluator, and I accept those treatment options.
Consent to Services Enrollment AgreementConsent to Services Enrollment Agreement • August 3rd, 2020
(“Board”). I acknowledge that I have been referred to Integrated Behavioral Health, LLC, aka Health Professionals’ Services Program (“Program”) by my Board and previous to such referral, I have been diagnosed by a Board-approved third party evaluator as having a:
