RHODE ISLAND ADULT DRUG COURT SUPERIOR COURT 250 BENEFIT STREET PROVIDENCE, RI 02903 IMPORTANT NOTICE An appointment has been scheduled for _________________________ at ___________ on _____________________________ in Courtroom ____ of the Rhode Island Superior Court, 250 Benefit Street, Providence, Rhode Island 02903. If for any reason you are unable to attend this appointment, please contact ________________________ at (401)_________ to reschedule. This appointment is for the purpose of conducting a drug abuse/use screening. In order for this screening to be properly conducted, it is required that participants consent to openly discussing personal and confidential information. It should also be understood that you may revoke this consent to speak with the Drug Court staff at any time during the screening, however, this may result in your disqualification from the Drug Court Program. This is a limited disclosure of information for the purpose of conducting the initial Drug Court screening and any disclosure is bound by Title 42 C.F.R; Part 2, which governs the confidentiality of substance abuse patient records. The Federal Rules prohibit further disclosure of this information unless such a disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by Title 42 CFR, Part 2. It is a crime to violate this Federal confidentiality requirement, which the participant may report to the appropriate authorities. The Federal Rules further restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. However, federal law does not protect information relating to crimes committed on the premises of the program, crimes against program personnel, or the abuse or neglect of a child. The undersigned hereby agrees to the foregoing and that his/her consent to this drug abuse/use screening is not the product of force or coercion. ____________________________________ Signature of Participant Date American LegalNet, Inc. www.FormsWorkFlow.com