A standard form created to facilitate reports from CMS PHR Committees on our participants
Can delete all the yellow highlighted portion and print on their own Letterhead
County Medical Society Quarterly Status Report to TXPHP
All records and information maintained by the TXPHP are confidential under Sec. 167.010 of the Medical Practice Act and are not subject to disclosure.
To: Medical Director/Clinical Coordinator
Texas Physician Health Program
333 Guadalupe, Tower 2, Suite 520
Austin, TX 78701
Email:
Re: ______
Name of TXPHP Participant TXPHP #
Date: ______
What follows accurately reflects the joint opinion of the above named TXPHP participant (circle appropriate answer – please amplify on any “NO” answer):
1. YES NO Compliance with attendance in CMS PHR Committee meetings is appropriate in frequency and participation.
2. YES NO Behavior indicates a continuing change consistent with adequate recovery efforts.
3. YES NO To our knowledge, his/her family is supporting his/her recovery efforts.
4. YES NO To our knowledge, no (new) legal issues have surfaced (“yes”= no new issues)
5. YES NO To our knowledge, he/she has been compliant with their Monitoring and Assistance Agreement with TXPHP and any additional agreement with our Committee.
6. YES NO To my knowledge, the participant’s level of involvement in the recovery process demonstrates an appropriate commitment to the process.
7. YES NO N/A He/she states that random urine testing is being performed and the specimen collection is always observed by lab personnel.
If you would like to speak with the Medical Director about any additional concerns you have regarding the above TXPHP participant, please indicate by marking an “X” in the checkbox, otherwise leave checkbox blank: Enter phone number below and preferred day and time to call.
Phone: ______Day of Week and Time: ______
Signed,
______
CMS PHR Chair or Designee’s Typed/Printed Name & Signature