(1)A licensee may only self-refer to the program if the licensee’s board has adopted a rule permitting self-referrals.
(2)Provisional Enrollment. To be provisionally enrolled in the program, a self-referred licensee must:
(a)Sign a written consent allowing disclosure and exchange of information between the program or the program’s contractor, as applicable, the licensee’s employer, independent third-party evaluators, and treatment providers;
(b)Sign a written consent allowing disclosure and exchange of information between the program or the programs’ contractor, as applicable, the board, the licensee’s employer, independent third-party evaluators and treatment providers in the event the program determines the licensee to be in substantial noncompliance with his or her provisional monitoring agreement.;
(c)Sign a written statement that the licensee has agreed to report any arrest for or conviction of a misdemeanor or felony crime to the program within three business days after the licensee is arrested or convicted;
(d)Attest that the licensee is not, to the best of the licensee’s knowledge, under investigation by his or her board; and
(e)Agree to and sign a monitoring agreement.
(3)Enrollment: To move from provisional enrollment to enrollment in the program, a self-referred the licensee must:
(a)Obtain at the licensee’s own expense and provide to the program, an independent third-party evaluator’s written evaluation containing a DSM diagnosis and diagnostic code, treatment recommendations, and practice restrictions, if any;
(b)Agree to cooperate with the program’s investigation to determine whether the licensee’s practice while impaired presents or has presented a danger to the public; and
(c)Enter into an amended monitoring agreement to reflect the treatment recommendations of the independent third-party evaluator and the program’s practice investigation.
(4)Once the program provisionally enrolls a self-referred licensee in the program failure to complete enrollment constitutes substantial non-compliance and must be reported to the board.
(5)The program may not report a self-referred licensee’s enrollment in or successful completion of the program to the licensee’s board.
Rule 415-065-0040 — Self-Referrals,