SAP Informed Consent for Treatment

 SERVICES OFFERED: PDF Evaluations provides SAP evaluations only. Initial evaluation, referral(s) to appropriate level of care/addiction education, follow-up evaluation, and follow-up testing plan.

 APPOINTMENTS: Appointments are times that are reserved for you. It is important that if circumstances arise which require you to change your appointment for the SAP Evaluation, we ask that you provide us with at least 24 hours’ notice. This will allow us to offer your time to another patient. We charge the $50.00 for appointments not cancelled with at least 24 hours’ notice.

 COST FOR SERVICES: The fee for the SAP Evaluation is $400.00, if paying by credit card the fee is $415.00. The SAP fee is not covered by insurance and would need to be paid in full at the time of the Initial SAP Evaluation. We accept cash, bank check, Venmo or PayPal.

 RANDOM SCREENS: You may be required to submit random drug screens at part of your substance abuse treatment plan. This service may be covered by your insurance company. If you fail to submit a requested screen by a treatment provider, it will be counted as a “refusal” which is the same as a positive screen.

 HEALTH INSURANCE: Most health insurance policies cover the services that we may recommend: outpatient counseling, intensive outpatient counseling, partial hospitalization program, and inpatient.

They do not cover the fee for the SAP evaluation.

 CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission except where disclosure is required by law.

 DEPARTMENT OF TRANSPORTATION: According to the DOT guidelines, a SAP may disclose the Initial Evaluation, recommendations, the Follow-up Evaluation, drug testing results, notice of compliance, and the follow-up testing plan to the designated employer representative (DER) without a written release according to 49 C.F.R. part 40

 WHEN DISCLOSURE IS REQUIRED OR MAY BE REQUIRED BY LAW: Some of the circumstances where disclosure is required or may be required by law are: where there is a reasonable

suspicion of child, dependent, or elder abuse and/or neglect. Where a client presents a danger to self or to others. Disclosure may also be required pursuant to a legal proceeding by or against you if a subpoena is issued. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the records and/or testimony by PDF Evaluations.

 CONSULTATION: PDF Evaluations consults with other professionals and in supervision regarding their clients; however, each client's identity remains completely anonymous and confidentiality is fully maintained.

 E–MAILS, CELL PHONES, COMPUTERS, AND FAXES: It is very important to be aware that computers and unencrypted e-mail and texts can be accessed relatively easily by unauthorized people, therefore, it can compromise the privacy and confidentiality of such communication. E-mails and texts are vulnerable to such unauthorized access. Due to the fact that communication companies may have unlimited and direct access to all e-mails and texts that go through them. While data on PDF Evaluations server is secure, e-mails are not.

 It is always a possibility that faxes, texts, and email can be sent erroneously to the wrong address and computers.

 If you communicate confidential or private information via unencrypted e-mail, texts or fax or via phone messages, we will assume that you have made an informed decision, we will view it as your agreement to take the risk that such communication may be intercepted, and we will honor your desire to communicate on such matters.

 RECORDS AND YOUR RIGHT TO REVIEW THEM: PDF Evaluations retains clinical records only as long as is mandated by Rhode Island law and DOT regulations. As a client, you have the right to review or receive a summary of your records at any time.

No records will be released without a signed release of information, except where permitted by DOT regulations under 49 C.F.R. part 40.

 TELEPHONE & EMERGENCY PROCEDURES: If you need to contact PDF Evaluations between meetings, please leave a message at (857) 266-7088 or email: liamlane.sap@gmail.com and your request will be returned as soon as possible. If an emergency situation arises and you need to talk to someone right away call 911. Please do not use email, texts, or faxes for emergencies.

 SOCIAL NETWORKING AND INTERNET SEARCHES: We do not accept friend requests from current or former clients on social networking sites, such as Facebook. We believe that adding clients as friends on these sites and/or communicating via such sites is likely to compromise their privacy and confidentiality. For this same reason, we request that clients not communicate via any interactive or social networking web sites.