Forms – Peer Health Assistance Programs

Program information and forms are available below. Participant information is available on the Client Site.

 

Release of Information Forms

 

Program Participant Forms

Rehabilitation Contract Reports

Rehabilitation Contract  reports are due on the 4th of the month. (Reports for the January reporting period are due February 4th.) 

Fax reports to:  720.213.1007 (Last Name A – L)   or    720.213.0002  (Last Name M – Z)

Email reports to: reports@peerassist.org 

Notice to clients: Standard email is an unsecured method of correspondence; therefore reports submitted via this method may be at risk for interception. PAS uses ZixCorp encryption for all email communication with clients.

Participants may choose one of the four Self-Status Reports to submit each reporting period, it is not necessary to submit all four versions.

 Addictionologist Report – 9/13
 
Annual History & Physical – 4/17
 
Meeting Verification– 8/13
 

Group Meeting Verification – 8/13

Opiate Replacement Therapy Report –4/13

Pain Management Provider Report – 4/13

PDMP Record Request – Email Receipt – 7/16

Dental Practice Monitor Report – 4/13

Mental Health Professional Practice Monitor Report  – 3/15

Nursing Practice Monitor Report  – 4/13

Veterinarian Practice Monitor Report – 7/16

Psychiatrist Report –4/13

Self Status –4/13

Self Status Education Employment Report – 4/13

Self Status Monthly Recovery Plan – 4/13

Self Status Wellness Plan – 4/13

Sponsor Report –4/13

LPN Supervisor Report – 4/13

RN Supervisor Report (Non-Clinical) – 4/13

RN Supervisor Report –8/15

Pharmacist Supervisor Report – 4/13

Supervisor Report – Veterinarian  -4/13

Mental Health Professional Supervisor Report– 3/15

Chiropractor Supervisor Report –4/13

Registered Dental Hygenist Supervisor Report –4/13

Respiratory Therapist Supervisor Report -4/13

Surgical Assistant Supervisor Report – 4/13

Therapist Report4/13

Therapist-Psychologist Report –9/13

Treatment Provider Report –4/13