Dah H 68 5 Form PDF Details

Dah H 68 5 form is a document used to report the health of an employee. The form is completed by a doctor and provides information on the employee's current health condition, any limitations due to illness or injury, and potential treatments or accommodations that may be necessary. The Dah H 68 5 form is important for employers to have in case they need to make any workplace accommodations for an employee who is not able to fully perform their job duties.

QuestionAnswer
Form NameDah H 68 5 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesdah_h68 googlecom cyberdrive illinois dah form

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ILLINOIS PETITIONER TREATMENT VERIFICATION

Office of the

Secretary of State

DEPARTMENT OF

ADMINISTRATIVE HEARINGS

Additional forms may be obtained at

www.cyberdriveillinois.com

The rules of the Secretary of State’s Department of Administrative Hearings require a petitioner to document completion of any recommended treatment or provide a treatment waiver as recommended in the Treatment Needs Assessment (TNA). This form may be completed and submitted for this purpose. If more space is needed, attach additional sheets.

Copies of the following documents must be attached to this form:

 

1)

Individualized Treatment Plan

2) Discharge Summary

3) Continuing Care Plan

4)

Continuing Care Status Report

5) Continuing Care Summary Report or Treatment Waiver

PETITIONER INFORMATION:

Name: (Last, First, Middle)

 

 

 

 

Illinois Driver’s License Number:

 

Address: (Street/City/State/ZIP)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sex:

 

Date of Birth:

 

 

Home Telephone Number:

 

Work Telephone Number:

 

 

 

 

n M

n F

 

/

/

(

)

 

 

(

)

1.Referral Source: __________________________________________________________________________________________

2. Admission Date: ____________________________________ Discharge Date: ______________________________________

(Primary treatment only; not follow-up/aftercare)

3.Admission Diagnosis: _____________________________________________________________________________________

________________________________________________________________________________________________________

Discharge Diagnosis: ______________________________________________________________________________________

________________________________________________________________________________________________________

OR

TNA Date: _________________________________________ Diagnosis: ___________________________________________

____________________________________________________

4.Treatment Modality:

n

Outpatient counseling

Number of hours completed: ___________________________

n

Intensive outpatient counseling

Number of hours completed: ___________________________

n

Inpatient

Number of days in inpatient treatment: ___________________

nIndividual therapy

nGroup therapy

Printed by authority of the State of Illinois. June 2012 — 1 — DAH H 68.5

1

5.Prognosis after completing treatment and/or TNA. Must include a discussion of what the petitioner appears to have gained from treatment and whether it has substantially reduced the potential for future alcohol/drug-related problems.

6.Continuing Care Status:

n Petitioner has completed continuing care (summary report required).

n Petitioner is currently involved in a continuing care plan (status report required). n Petitioner has completed a continuing care plan.

n Petitioner has not initiated continuing care. n Continuing care waived (rationale required).

n Petitioner has initiated but failed to complete a continuing care plan for the following reason:

7.Rationale for: a) any modification in the number of treatment hours or change in treatment modality as recommended by the petitioner’s last evaluation; b) treatment waiver; or c) additional treatment recommendations as a result of the TNA.

If a petitioner classified as “High Risk” has been determined to be “Non-Dependent,” a detailed explanation by the treatment provider as to why dependency was ruled out must be submitted.

I certifiy that I have accurately reported the data collected and required to complete the treatment verification. I also have attached copies of the petitioner’s Individualized Treatment Plan, Discharge Summary, Continuing Care Plan, Continuing Care Status Report, and Continuing Care Summary Report or TNA.

Provider’s Name: (type or print)

Provider’s Signature:

Date:

Provider’s Title:

Telephone Number:

Program Name:

Accreditation/License Number:

Address: (Street/City/State/Zip)

2

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Step 2: As you start the editor, you will find the document prepared to be filled in. Besides filling out different fields, it's also possible to do various other actions with the Document, particularly writing any textual content, modifying the original text, inserting images, signing the form, and much more.

As for the blanks of this particular PDF, this is what you should consider:

1. Firstly, while filling out the Dah H 68 5 Form, start with the part with the subsequent blank fields:

The way to fill in Dah H 68 5 Form part 1

2. After filling in the last step, go to the next stage and enter the essential particulars in all these blank fields - TNA Date Diagnosis, TNA Date, Treatment Modality, n Outpatient counseling Number of, n Intensive outpatient counseling, n Inpatient Number of days in, n Individual therapy, n Group therapy, and Printed by authority of the State.

TNA Date Diagnosis, Treatment Modality, and Printed by authority of the State of Dah H 68 5 Form

Concerning TNA Date Diagnosis and Treatment Modality, be certain that you review things here. These could be the key ones in this PDF.

3. Completing Prognosis after completing, from treatment and whether it has, Continuing Care Status, n Petitioner has completed, n Petitioner is currently involved, n Petitioner has completed a, n Petitioner has not initiated, n Continuing care waived rationale, and n Petitioner has initiated but is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Dah H 68 5 Form conclusion process explained (step 3)

4. Filling out Rationale for a any modification, the petitioners last evaluation b, If a petitioner classified as High, I certifiy that I have accurately, Providers Name type or print, Providers Signature, Date, Providers Title, and Telephone Number is crucial in the fourth step - make certain that you devote some time and fill in every blank!

Dah H 68 5 Form conclusion process shown (portion 4)

5. Since you get close to the end of this file, you'll notice a few more points to do. Particularly, Program Name, AccreditationLicense Number, and Address StreetCityStateZip should be filled in.

Dah H 68 5 Form conclusion process shown (portion 5)

Step 3: Prior to submitting this file, make certain that blanks were filled out as intended. Once you think it is all good, press “Done." Get your Dah H 68 5 Form the instant you sign up for a 7-day free trial. Readily gain access to the pdf file within your FormsPal account page, together with any edits and adjustments being all preserved! FormsPal guarantees protected document editor devoid of personal information recording or distributing. Rest assured that your details are secure here!

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