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Form Doh 422-066 - Psychiatric/psychological Consultant'S Compliance Form - Washington State Department Of Health

PSYCHIATRIC/PSYCHOLOGICAL CONSULTANT’S COMPLIANCE FORM

Deliver this form to the attending physician who will mail it to:

State Registrar, Center for Health Statistics,

P.O. Box 47856, Olympia, WA 98504-7856

PATIENT INFORMATION

PATIENT’S NAME (LAST, FIRST, M.I.):

DATE OF BIRTH:

REFERRING/PRESCRIBING PHYSICIAN

REFERRING PHYSICIAN’S NAME (LAST, FIRST, M.I.):

TELEPHONE NUMBER:

(

)

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PSYCHIATRIC / PSYCHOLOGICAL EVALUATION

1. MEDICAL DIAGNOSIS

DATE(S) OF EXAMINATION(S):

2. PSYCHIATRIC / PSYCHOLOGICAL EVALUATION

PSYCHIATRIC/PSYCHOLOGICAL CONSULTANT’S INFORMATION

I have determined through evaluation that the above-named patient is not suffering from a psychiatric or psychological

disorder or depression causing impaired judgment, in conformance with chapter 70.245 RCW.

CONSULTANT’S ORIGINAL SIGNATURE AND TITLE (e.g., M.D., Ph.D., etc.):

CONSULTANT’S NAME (PRINTED):

DATE:

MAILING ADDRESS:

CITY, STATE AND ZIP CODE:

TELEPHONE NUMBER:

(

)

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DOH 422-066 June 2016

Form Doh 422-066 - Psychiatric/psychological Consultant'S Compliance Form - Washington State Department Of Health