LAND, SEA AND AIR MEDICAL REVIEW SPECIALISTS

Arnold D. Panzer, M.D.
Diplomate American Board of Internal Medicine
Certified Medical Review Officer
Senior Aviation Medical Examiner
#16942-4

910 Route 109
North Lindenhurst, NY  11757
(631) 225-3060
Fax: (631) 225-3064


SAP Certification Form
SAP Information:
SAP NAME:    
      
ADDRESS:   
  
TELEPHONE #:   
  
FAX #:   
  
OFFICE HOURS:        
         
APPOINTMENT
PROCEDURES:		       
FEE:        

License or Certification
Licensed Physician (Medical Doctor or Doctor of Osteopathy)
Licensed or certified psychologist
Licensed or certified social worker
Licensed or certified Employee Assistance Professional (EAP)
Addiction counselor certified by the National Association of Alcoholism & Drug Abuse Counselors
Certification Commission
Addiction counselor certified by the International Certification Reciprocity Consortium Alcohol and other
Drug Abuse

I hereby certify that I am qualified to perform U.S. Department of Transportation Substance Abuse Professional (SAP) evaluations.  I certify that I have received, read, understand and will follow the Department of Transportation SAP guidelines for performing DOT SAP evaluations.  I further certify that I hold the license/certification indicated above, and that I have knowledge of and clinical experience in the diagnosis and treatment of alcohol and controlled substance-related disorders.

_______________________________________                                          _______________________
Name (please print)                                                                                          Date

_______________________________________
Signature

Complete the form, and submit (via fax or mail) along with copies of credentials/licenses and documentation outlining your experience in Chemical Dependency Treatment Field.