Quarterly Practice Liaison Report Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.HAVEN ID #Reporting PeriodJanuary to March – due April 15April to June – due July 15July to September – due Oct. 15October to December – due Jan. 15Frequency of contactHas there been any change in practice responsibilities since the date of the last report?Has this professional had any extended or unexplained absences?Are controlled substances and all other medications prescribed and/or administered appropriately?Does the health care professional appear to be practicing in a safe and skillful manner?Use this space for further comments, questions, or concerns:Signature Clear SignatureName *FirstLastDateAddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhoneI am familiar with HAVEN expectations that any concerns about this individual should be reported to HAVEN immediately, by calling 860.828.3175. More information about HAVEN is available at www.haven-ct.org or by calling us at any time.I AgreeI DisagreeReports are due following the completion of each quarter, by April 15, July 15, October 15, and January 15, respectively.This information has been disclosed to you from records protected by State and Federal confidentiality rules including 42 CFR Part 2 and Conn. Gen. Stat. Sec. 19a-12a. State and Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2 and State law. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. This information is also protected from disclosure under State law and information contained herein may not be reproduced or disclosed unless otherwise required by law. 42 CFR Part 2 prohibits unathorized disclosure of these recordsSubmit
