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Report of addiction evaluation - dot.nd.gov

Report of addiction evaluation - dot.nd.gov 2026

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The document is a confidential report from the North Dakota Department of Transportation regarding addiction treatment for drivers. It outlines the process for verifying a patient's completion of an addiction education program, including details about the patient, treatment program, and qualified professional. The report emphasizes the confidentiality of patient records and includes consent for information release to comply with statutory requirements.

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Click ‘Get Form’ to open it in the editor.
Begin by filling in the 'FROM' section with the name of the licensed addiction treatment program or counselor, along with their contact information.
In the 'REGARDING' section, enter the patient's name, telephone number, address, and date of birth. Ensure all details are accurate for proper identification.
Complete the 'VERIFICATION OF TREATMENT' section by indicating the enrollment date and completion date. Select the type of treatment received from the provided options.
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, confirm your consent for information sharing by signing and specifying any expiration conditions for this consent.
Finally, review all entries for accuracy before saving or printing your completed form for submission.

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