• Ohio PHP
  • @OhioPHP
  • OhioPHP

Ohio Physicians Health Program

130 E. Chestnut Street, Suite 400

Columbus, Ohio 43215

614.841.9690

careers​

© 2019 Ohio Physicians Health Program, Inc. 

GENERAL FORMS

OPHP provides written reports on program compliance for those participants requesting updates. Communication with any third party is strictly prohibited and information is only released with written authorization. In order to process this request, please complete and return both forms below to: info@ophp.org or fax to (614) 469-9580. For active participants, the cost of this request is included in the monthly monitoring fee. For any inactive participant who is no longer enrolled for monitoring and advocacy services, the cost of this report is $125.

 

Advocacy Request Form

Payment Form

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POTENTIAL PARTICIPANT FORMS

Our mission, “to facilitate the health and wellness of healthcare professionals in order to enhance patient care and safety” guides our staff of caring professionals.  In order to process your enrollment, please complete and return the below forms to the OPHP office at your earliest convenience or send directly to info@ophp.org or fax to (614) 469-9580.  For more information, please contact OPHP at (614) 841-9690 or visit our FAQ.

Demographic & Intake Form

Volunteer Peer Monitor Form

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CURRENT PARTICIPANT FORMS

On a quarterly basis, OPHP completes a Quarterly Status Report (QSR) documenting your compliance with your OPHP agreement.   In order for your report to be complete, you will need to provide the below documents.  Your materials will be due by the 23rd of the month corresponding with your assigned reporting period.  If they are not received by the due date, your quarterly report will be incomplete.

 

Please send your materials to Jill K. Aitcheme, CDCA, Compliance Coordinator. If you have any questions, you can reach her at

(614) 841-9690, ext. 21 or by email at jaitcheme@ophp.org.

 

Self Report:

Self Report - Substance Use Disorder Agreements

Self Report - Mental Health, Behavioral, Toxicology Testing Agreements

 

Volunteer Peer Monitor Report (VPMR):

VPMR - Substance Use Disorder Agreements

VPMR  -Mental Health, Behavioral, Toxicology Testing Agreements

 

Aftercare Report
Medication Compliance Report

Medication Log

Meeting Attendance Logs

Prescribing Physician Report

Psychiatrist Report

Psychotherapy Report

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