OPT Review Form Client Name(Required) First Last Client ID Date of Birth(Required) MM slash DD slash YYYY Obtain Checkbox OBTAIN: Participant’s initial and updated treatment plans must include the goal of obtaining a physical exam until the goal has been met. Required Checkbox REQUIRED WITHIN 30 DAYS: A physical exam is required within 30 days of Intake due to the following health concerns: REQUIRED WITHIN 30 DAYS DESCRIPTION RECEIVED Checkbox RECEIVED: Participant has obtained a copy of a physical exam that has been completed within 12 months from intake date or as required. Physical has been reviewed by program physician. Date Received/Reviewed MM slash DD slash YYYY Notes From DoctorPhysician SignatureDate Signed MM slash DD slash YYYY
