REQUEST FOR
CHANGE TO RMA
Licensee’s Name:
Date:
Support for:
Return to Work
Decreased Therapist Visits
ONE
Decreased UDS
Decreased Addictionist Visits
Decreased NA/AA Meetings
No Controlled Substance Restrictions
Request
Decreased NSG Meetings
Completion of ISNAP program
Per Form
Other:
WORK SITE MONITOR’S SUPPORT:
Work Site Monitor, please give reason(s) for No or Yes answers.
No
Yes
Work Site Monitor would rather contact ISNAP
N/A – NO Addictionist
Reason:
Name:
Phone#:
Address:
Signature:
Date:
THERAPIST’S SUPPORT:
Therapist, please give reason(s) for No or Yes answers.
No
Yes
Therapist would rather contact ISNAP
N/A – NO Addictionist
Reason:
Name:
Phone#:
Address:
Signature:
Date:
ADDICTIONIST’S SUPPORT:
Addictionist, please give reason(s) for No or Yes answers.
No
Yes
Addictionist would rather contact ISNAP
N/A – NO Addictionist
Reason:
Name:
Phone#:
Address:
Signature:
Date:
SPONSOR’S SUPPORT:
Sponsor, please give reason(s) for No or Yes answers.
No
Yes
Sponsor would rather contact ISNAP
N/A – NO Addictionist
Reason:
Name:
Phone#:
Signature:
Date:
Licensee’s Signature
Date
FOR ISNAP’S USE ONLY
Approved
Denied
ISNAP Staff Signature & Date
Form# 800
Revised 06/12/13