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Authorization Forms

  • Select the correct authorization form(s) from the Authorization Forms section below.
  • Please print all information correctly and clearly.
  • Important: The authorization is to be dated and signed by you, the participant.
  • You will send the authorization to HPSP, and HPSP will send it to the individual to whom you authorize in writing.

For whom do I sign authorizations?

At the time of your enrollment in HPSP, we ask you to identify past and current treatment providers, hospitalizations, and pharmacies. HPSP uses this information to determine whether you have an illness that warrants monitoring, and if so, to help establish a Monitoring Plan that best reflects your needs and public safety. After participation commences, we will seek information from current treatment providers, supervisors (work site monitors), and others to assist us in documenting your illness management and work performance. Keeping authorizations current is essential to your compliance with monitoring.

What if I decide not to provide or retract a written authorization?

HPSP needs to communicate with your providers and work site for effective monitoring. You are not legally obligated to releases requested information to HPSP, however, if you do not, HPSP will close your file and make a report to your licensing board or regulatory authority.

Why do I need to sign authorizations for the same person more than once?

Authorizations are valid for one year from the date of signature. Therefore, to maintain compliance with HPSP, you need to ensure all authorizations are current. HPSP will notify you when authorizations must be renewed.

Authorization Forms

Substance Use Providers

Professional Support Group Authorizations

  • Dentists Concerned for Dentists: DCD
  • Pharmacy Recovery Network: PRN

Work Related Authorizations

Medical and Pharmacy Records Requests

Miscellaneous Authorizations

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