A long-exposure night shot from an elevated vantage point, white and red light trails from passing vehicles curving around a wooded hill below, a faint town glow visible in the distance, and a deep royal blue sky with scattered bright stars above a misty horizon, representing the federally governed SAP evaluation process and the path forward available through Availia TeleHelp PLLC in Spokane and Washington State.

SAP Informed Consent

Required before your DOT SAP evaluation.

Covers the role of the SAP, confidentiality limits, your rights under 49 CFR Part 40, & the fee schedule for SAP services.

Please Note:

Read this form carefully before your SAP evaluation.

It describes the role of the SAP, the limits of confidentiality specific to DOT evaluations, your rights under 49 CFR Part 40, and the fee schedule for SAP services.

Complete and sign this form before your evaluation begins.

If you have questions about any of the information contained here, contact Availia at info@availia.com or 509-495-1222 before your appointment.

Availia Client Information

First name

Last name

Date of Birth

Month

Day

Year

Purpose of This Document

This document applies only to DOT Substance Abuse Professional (SAP) Evaluations. It describes your rights and the limits of confidentiality specific to this service. Read it carefully before signing.

What a SAP Assessment Is & Is Not

The SAP is not your treating provider and does not provide therapy, counseling, or case management. The SAP does not advocate for you or your employer. The SAP's role is defined by federal regulation: evaluate, recommend, and monitor. The SAP's function is to protect public safety, not to support any particular employment outcome.

Verified Test Results are Conclusive

Federal law (49 CFR § 40.293(g)) requires the SAP to treat your verified positive result as conclusive. No explanation you offer can change the evaluation outcome. This includes claims of legal prescription, hemp oil, CBD, secondhand exposure, test inaccuracy, or any other explanation. Statements you make about the incident will be documented as clinical observations relevant to your assessment. They cannot be used to challenge the test result.

Confidentiality Limits

Standard clinical confidentiality does not prevent the following, which are required by federal regulation. The SAP report is sent directly to your Designated Employer Representative (DER). You cannot prevent this. If your employer uses a C/TPA, the report may also be sent to the C/TPA simultaneously. SAP records may be disclosed to DOT agency representatives conducting audits or safety investigations. SAP records may be disclosed to the National Transportation Safety Board (NTSB) in an accident investigation. None of the above require your consent.

Your Right to a Copy of the Report

You may request a copy of any SAP report issued about you. Requests must be in writing. Copies are provided within 10 business days. Your follow-up testing schedule will be removed before the copy is provided. Federal law prohibits disclosing it to you. A fee limited to the cost of preparation and reproduction may apply.

No Second Assessment

Federal law (49 CFR § 40.295) prohibits you from seeking a second SAP evaluation to obtain a different recommendation. If you obtain one, your employer cannot rely on it. Only the SAP who conducted your evaluation may update the recommendation, and only based on new clinical information.

MRO Consultation

For drug-related violations, the SAP may consult the Medical Review Officer (MRO) who verified your test result. This may occur without your consent. The MRO is required by law to cooperate.

No Waiver Required

You are not required to sign any waiver of liability, release, or indemnification agreement in connection with this evaluation. Federal law (49 CFR § 40.355(a)) prohibits it. This document does not contain one.

Remote & Virtual Assessment Services

If your evaluation is conducted by video, you must be physically located in Washington State during the session. A live video & audio connection is required. A phone call alone is not sufficient. You are responsible for securing a private location. If connection quality is insufficient at any point, notify the SAP immediately. The evaluation will pause or reschedule rather than continue on a badconnection. If you are

not in Washington State, notify the SAP before the session begins.

Questions - Provider Contact Details

Services are provided by:

Duncan True, SUDP, NCACI, NCSE

Administrator, Availia TeleHelp PLLC

316 West Boone Avenue Suite 669

Spokane WA 99201, 509-495-1222.

SAP Fee Schedule

Payment is due at the time of service. The SAP evaluation fee is the responsibility of the employee unless otherwise arranged with the employer. Availia TeleHelp PLLC does not bill insurance for SAP evaluation services. No sliding scale is available for SAP services.

Initial SAP Evaluation: $350

Follow-Up SAP Evaluation: $150

SAP Bundle (Both Evaluations, Paid Up-Front): $450 (Saves 10%)

Client Acknowledgments

By submitting this form I confirm I have read and understood this Informed Consent and Disclosure, including the role of the SAP,

the limits of confidentiality, my rights under 49 CFR Part 40,

and my financial responsibility for SAP services.

Availia TeleHelp PLLC and signee agree that any digital signature may serve the full legal effect and function of a handwritten signature.

Signature

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