"Substance Abuse Professional Referral Form" - Ohio

Substance Abuse Professional Referral Form is a legal document that was released by the Ohio Department of Transportation - a government authority operating within Ohio.

Form Details:

  • Released on January 1, 2016;
  • The latest edition currently provided by the Ohio Department of Transportation;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Ohio Department of Transportation.

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CONFIDENTIAL
SUBSTANCE ABUSE PROFESSIONAL REFERRAL
I acknowledge that I have received a referral to a Substance Abuse Professional in accordance with 49
CFR Part 655.62.
The cost of this service will be paid by: ____________________________________________________.
Substance Abuse Professional Referral:
Name: ________________________________________________________________________
Address: ______________________________________________________________________
City/State: _____________________________________________________________________
Phone: ________________________________________________________________________
Alternate Substance Abuse Professional Referral:
Name: ________________________________________________________________________
Address: ______________________________________________________________________
City/State: _____________________________________________________________________
Phone: ________________________________________________________________________
I, _____________________________________________, have received a copy of this referral.
Employee/Applicant Full Name
_______________________________________________
_________________________________
Employee/Applicant Signature
Date
_______________________________________________
_________________________________
Agency Representative Full Name, Title
Telephone Number
_______________________________________________
Agency Name
_______________________________________________
_________________________________
Agency Representative Signature
Date
If the employee refuses to sign this form, please document why
1/2016
CONFIDENTIAL
SUBSTANCE ABUSE PROFESSIONAL REFERRAL
I acknowledge that I have received a referral to a Substance Abuse Professional in accordance with 49
CFR Part 655.62.
The cost of this service will be paid by: ____________________________________________________.
Substance Abuse Professional Referral:
Name: ________________________________________________________________________
Address: ______________________________________________________________________
City/State: _____________________________________________________________________
Phone: ________________________________________________________________________
Alternate Substance Abuse Professional Referral:
Name: ________________________________________________________________________
Address: ______________________________________________________________________
City/State: _____________________________________________________________________
Phone: ________________________________________________________________________
I, _____________________________________________, have received a copy of this referral.
Employee/Applicant Full Name
_______________________________________________
_________________________________
Employee/Applicant Signature
Date
_______________________________________________
_________________________________
Agency Representative Full Name, Title
Telephone Number
_______________________________________________
Agency Name
_______________________________________________
_________________________________
Agency Representative Signature
Date
If the employee refuses to sign this form, please document why
1/2016