EmailMe Form - SAP - CONSENT TO SERVICES AGREEMENT

Consent to Services Agreement

CONSENT TO SERVICES AND PAYMENT AGREEMENT: This Consent to Services and Payment Agreement ("Agreement") is entered into by and between Anchor Behavioral Centers, Inc. ("Agency") and ("Client") as signed and dated below. For good and valuable consideration and at Client's request, Agency shall provide SAP RTD (Return to Duty) professional services to Client on the terms provided herein. Included SAP Services: Initial evaluation, Remediation plan, Follow-up evaluation, Consolidated report and follow-up testing recommendations. Note: Follow-up testing recommendations will only be provided to their current or prospective employer, C/TPA consortiums.  Cost for SAP services: Standard rate is $625. All individualized / negotiated payment terms will be reflected on the service invoice. Any incremental services e.g., additional employer reports (over 3) requested by the “Client” will be provided at an administrative cost of $25 per request. If it is not your employer’s policy to pay for SAP evaluation services, you are financially responsible. All expenses that arise from treatment and/or education, as recommended by SAP, will be your financial responsibility, if not covered by your employer. STATEMENT OF UNDERSTANDING AND RELEASE Related to Department of Transportation’s (DOT) SAP return-to-duty process: Welcome to Anchor Behavioral Centers, Inc. This service is provided to address the substance abuse issues that affect public safety under 49 CFR Part 40; Subpart O - Substance Abuse Professionals and the Return-to-Duty Process. Anchor Behavioral Centers, Inc., an Illinois corporation, agrees to provide to Client, comprehensive Substance Abuse Professional (SAP) evaluation services in accordance with 49 CFR Part 40; Subpart O—Substance Abuse Professionals and the Return-to-Duty Process. I do authorize Anchor Behavioral Centers, Inc. to release to my current or to a prospective employer and C/TPAs (at my request) all written evaluations and reports on me in accordance with DOT Regulations. Relevant information for which I authorize Anchor Behavioral Centers, Inc. to release in accordance with DOT Regulations would include: 1. My violation of DOT regulations (prohibited conducts) 2. My drug and/or alcohol test results 3. The Substance Abuse Professional’s (SAP) synopsis of my treatment plan 4. SAP’s assessment evaluation and treatment plan 5. Diagnostic information, where applicable 6. Treatment progress reports 7. Program completion information, including discharge summary, if applicable 8. Program involvement dates, attendance reports Relevant information as it pertains to the SAP and return-to-duty process may be released to all Appropriate Personnel. The purpose of the exchange of information is to comply with DOT requirements that must be met before I may take a Return to Duty drug and/or alcohol test and prior to being considered for returning to the performance of safety-sensitive functions under DOT regulations. I understand that my records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2. Record Retention Authorization: “Agency,” is authorized by me to maintain and retain complete documentation of all SAP cases via comprehensive, detailed case notes and customized forms in accordance with this release and authorization. Lawful release of records is also permitted under the following conditions: if you pose a clear and imminent danger to self or others, if there is known or suspected child abuse or neglect, if medical records are court ordered by a judge compelling disclosure, when the SAP seeks medical or legal consultation, if the SAP is to make case records available, on request, to a DOT agency representatives and/or representatives of the National Transportation Safety Board in an accident investigation. CLIENT AGREES THAT IF THERE IS EVER ANY LEGAL DISPUTE BETWEEN THEM AND THE SAP SERVICE PROVIDER AND OR AGENCY THAT THEY HEREBY IRREVOCABLY WAIVE THE RIGHT TO ANY JURY TRIAL AND THAT ANY TRIAL SHALL BE A BENCH TRIAL LOCATED IN THE CITY OF CHICAGO, STATE OF ILLINOIS. THIS AGREEMENT AND THE RIGHTS OF THE PARTIES HEREUNDER SHALL BE GOVERNED BY AND INTERPRETED IN ACCORDANCE WITH THE INTERNAL LAWS OF THE STATE OF ILLINOIS.

Enter name of current employer if applicable

Name ("Client") *

First Last

Mobile Phone *

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Email *

Date of Birth *

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Last 4 digits SS# *

CDL# *

Date of Violation *

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Type of Violation *

Test Type *

Substance Referenced *

Mailing Address *

Date *

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Client Signature *

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