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REPORT OF ADDICTION TREATMENT - North Dakota Department ... - dot nd 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by filling in the 'FROM' section with the details of the Licensed Addiction Treatment Program, including the counselor's name and contact information.
- In the 'REGARDING' section, enter the patient's name, telephone number, address, and date of birth. Ensure accuracy for proper identification.
- Complete the 'VERIFICATION OF TREATMENT' section by noting the dates of enrollment and completion, as well as selecting the type of treatment received.
- Have a Qualified Professional sign and date the form in the designated area, ensuring their license number is included.
- In the 'RELEASE OF INFORMATION' section, ensure that consent is provided for sharing information with the Driver License Division. Specify any expiration conditions for this consent.
- Finally, have both the patient/driver and Qualified Professional sign where indicated before submitting to ensure compliance with confidentiality regulations.
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