Get Ia Out-of-state Substance Abuse Evaluation/treatment Verification 2019-2025

Filling out the IA Out-of-State Substance Abuse Evaluation/Treatment Verification is an essential step for individuals cited for operating a vehicle under the influence. This guide provides clear and concise instructions to help you complete the form accurately and effectively online.

Follow the steps to complete the form successfully.

1. Click the ‘Get Form’ button to access the form and open it for editing.
2. In Section A, provide your personal information. Enter your last name, first name, middle initial, address, telephone number, city, state, date of birth in mm/dd/yyyy format, and zip code. Make sure all information is accurate to avoid any delays.
3. Proceed to Section B and fill in the evaluator's information. Include the name of the facility, the name of the evaluator, facility address, telephone number, city, and state. Answer whether the facility and/or evaluator is a licensed substance abuse treatment provider and, if yes, provide the licensing agency and license number.
4. In Section C, document the results of your substance abuse evaluation. Enter the date of evaluation, specify which diagnostic tools were utilized, and summarize the recommendations provided by the evaluator.
5. Continue to Section D if treatment was recommended. Specify if the treatment was successfully completed, including start and end dates. If treatment was at a different facility, provide that facility's name, address, and telephone number. Also, answer if the treatment facility is licensed and include the relevant licensing details.
6. Finally, fill out Section E with your name, title, and signature to attest that all information supplied is true and accurate. Review all sections to ensure completeness and accuracy.
7. Once all sections are completed, you can save your changes, download the document, print it, or share it as necessary.

Complete your IA Out-of-State Substance Abuse Evaluation/Treatment Verification form online today.