John's Law NJ Guidelines for the implementation of N.J.S.A. 39:4-50.23, the mandatory 12-hour impoundment of the motor vehicle operated by a person arrested for a violation of N.J.S.A. 39:4-50 (DWI) or N.J.S.A. 39:4-50.4a (Refusal to submit to chemical breath testing).

John's Law NJ Guidelines for the implementation of N.J.S.A. 39:4-50.23, the mandatory 12-hour impoundment of the motor vehicle operated by a person arrested for a violation of N.J.S.A. 39:4-50 (DWI) or N.J.S.A. 39:4-50.4a (Refusal to submit to chemical breath testing).1

ATTORNEY GENERAL LAW ENFORCEMENT DIRECTIVE NO. 2001-5
APPENDIX B
Guidelines for the implementation of N.J.S.A. 39:4-50.23, the mandatory 12-hour impoundment of the motor vehicle operated by a person arrested for a violation of N.J.S.A. 39:4-50 (DWI) or N.J.S.A. 39:4-50.4a (Refusal to submit to chemical breath testing).1
Purpose of Guidelines
The purpose of these Guidelines is to assist law enforcement agencies in fulfilling their statutory responsibilities under the provisions of N.J.S.A. 39:4-50.23. It is not the purpose of these Guidelines, however, to otherwise invalidate, supplement, modify or rescind any existing: ordinance or resolution adopted by a governing body; any existing policy of a law enforcement agency; or any contractual agreements with respect to the towing and removal of vehicles, the manner in which such vehicles are claimed by their owner or the fees related thereto. To the extent that the provisions of N.J.S.A. 39:4-50.23 may require a law enforcement agency to adjust its policies or practices, the law enforcement agency should contact their appropriate legal representative for legal advice.2
In addition, these Guidelines do not otherwise negate the holdings of the New Jersey Supreme Court, which interpret the constitution to allow the operator of a vehicle who has been arrested to make arrangements for the vehicle's immediate removal by another person present at the scene in lieu of impoundment by a law enforcement agency.
Another important aspect of this legislation is that subject to these Guidelines, a vehicle must be impounded for 12 hours from the time of arrest of the person operating that vehicle. Any release of the vehicle before the expiration of the 12-hour period of impoundment is
1 This DIRECTIVE and these Guidelines are also available on the Division of Criminal Justice Internet website at www.njdcj.org. Once at the website, to locate this DIRECTIVE, click at the tab "AG Directives," then locate this Directive by name or number. To locate these Guidelines, click at the tab "AG Guidelines," then locate "DWI Enforcement" and click on "John's Law, Guidelines for Vehicle Impoundment."
2 General legal advice for law enforcement agencies should be obtained from the following: municipal police departments from the Municipal Attorney or Solicitor; county law enforcement agencies from the County Counsel; bi-state law enforcement agencies from the general counsel for the bi-state agency; State law enforcement agencies from the assigned Deputy Attorney General in the Division of Law; Division of State Police from the Office of State Police Affairs. Legal advice on issues pertaining to criminal law and procedure should be obtained from the County Prosecutor or the Division of Criminal Justice.
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ATTORNEY GENERAL LAW ENFORCEMENT DIRECTIVE NO. 2001-5
- APPENDIX B -
GUIDELINES FOR MANDATORY 12-HOUR IMPOUNDMENT OF MOTOR VEHICLES
governed by specific provisions in the statute and by these Guidelines and Guidelines for the use of the POTENTIAL LIABILITY WARNING - N.J.S.A. 39:4-50.22 form, found in Appendix A of Attorney General Law Enforcement Directive No. 2001-5, P.L. 2001, c. 69, N.J.S.A. 39:4- 50.22 & 39:4-50.23. Release of an impounded vehicle after the expiration of the 12-hour period of impoundment will be governed by existing policies and procedures of the law enforcement agency.
Summary of N.J.S.A. 39:4-50.23
In summary, the primary provisions of N.J.S.A. 39:4-50.23 mandate that the law enforcement agency which has arrested a driver for a DWI or a Refusal violation must take two actions with regard to the vehicle operated by the arrested person.

N.J.S.A. 39:4-50.23(a)
N.J.S.A. 39:4-50.23(b)

"Whenever a person has been arrested for a violation of [N.J.S.A. 39:4-50] or . . . [N.J.S.A. 39:4-50.4a], the arresting law enforcement agency shall impound the vehicle that the person was operating at the time of the arrest." .
The vehicle which had been operated by the arrested person "shall be impounded for a period of 12 hours after the time of arrest or until such later time as the arrestee claiming the vehicle meets the conditions for release" under N.J.S.A. 39:4-50.23(d).

Although the first provision of the statute calls for an immediate impoundment of the vehicle being operated by the person arrested, that provision of the statute does not negate the constitutional right of the arrested person to make other arrangements for the removal of the vehicle by another person who is present at the scene of the arrest. Thus, if there is a passenger in the vehicle at the time the operator is arrested, the arrestee may permit that passenger to operate the vehicle or to make arrangements for its removal without the vehicle being impounded. Of course, the person remaining with the vehicle must possess a valid driver's license, be capable of operating the vehicle or making arrangements for its removal, and not be in violation of the motor vehicle laws of this State.
Additional provisions of the statute allow for the release of an impounded vehicle, prior to the end of the period of impoundment, subject to several conditions and compliance with the provisions of N.J.S.A. 39:4-50.23(d).
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ATTORNEY GENERAL LAW ENFORCEMENT DIRECTIVE NO. 2001-5
- APPENDIX B -
GUIDELINES FOR MANDATORY 12-HOUR IMPOUNDMENT OF MOTOR VEHICLES
Procedures
Other than the POTENTIAL LIABILITY WARNING - N.J.S.A. 39:4-50.22 form, to be given to a person summoned to transport or accompany an arrested person, these Guidelines do not require the use or adoption of any specific forms. To the extent that any existing forms of the law enforcement agency may require modifications or revisions to otherwise conform to the provisions of this statute, those modifications should be reviewed by the legal advisor to the law enforcement agency.
Arrest and Impoundment
When a law enforcement officer has arrested a person, based upon the officer's reasonable suspicion that the operator of a motor vehicle has been operating that vehicle while under the influence of intoxicating liquor or drugs, the provisions of N.J.S.A. 39:4-50.23 mandate that the vehicle being operated by the driver be impounded for 12 hours from the time of the arrest of the operator of the vehicle.
The procedure by which impoundment of the vehicle is to take place shall be governed by existing policies and procedures of the law enforcement agency. However, those policies and procedures must include a provision for the arrestee to permit another person, present at the scene, to operate the motor vehicle or to make arrangements for the removal of the vehicle.
If the vehicle is impounded, the person or party taking responsibility for the removal and impoundment of the vehicle must be informed that the vehicle cannot be released for 12 hours following the time of arrest, unless otherwise authorized by law and should be informed of the time of the arrest of the operator of the vehicle.
Release of a vehicle from impoundment before the expiration of the 12-hour period of impoundment.
An impounded vehicle may be released before the 12-hour period of impoundment has elapsed only under the following conditions.
1. If the vehicle is not owned or leased by the person arrested, then the owner or lessor can claim the vehicle at any time, provided that the owner or lessor satisfies the requirements of N.J.S.A. 39:4-50.23(d). Those requirements are set forth
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ATTORNEY GENERAL LAW ENFORCEMENT DIRECTIVE NO. 2001-5
- APPENDIX B -
GUIDELINES FOR MANDATORY 12-HOUR IMPOUNDMENT OF MOTOR VEHICLES
below under Release Requirements.
2. If the vehicle is owned or leased by the arrested person, then the vehicle may be released to another person only if the following conditions and requirements are satisfied.

• The arrestee has given his or her permission to the other person to operate the vehicle.
  
• The person to whom permission has been given accepts the conditions for release of the vehicle under the provisions of N.J.S.A. 39:4-50.23(d). See Release Requirements, below.
  
• The person to whom permission has been given has acknowledged, in writing, receipt of the POTENTIAL LIABILITY WARNING - N.J.S.A. 39:4-50.22.
  The manner and form by which permission to operate the impounded vehicle and the acceptance of the conditions for release of the impounded under the provisions of N.J.S.A. 39:4- 50.23(d) is to be executed are to be determined by each law enforcement agency.
  The receipt of acknowledgment of the POTENTIAL LIABILITY WARNING - N.J.S.A. 39:4-50.22 must be in conformance with the POTENTIAL LIABILITY WARNING - N.J.S.A. 39:4-50.22, Form & Guidelines, found in Appendix A of Attorney General Law Enforcement Directive No. 2001-5, P.L. 2001, c. 69, N.J.S.A. 39:4-50.22 & 50.23.3
  

Release Requirements
The provisions of N.J.S.A. 39:4-50.23(d) set forth several mandatory requirements on the person to whom an impounded vehicle is to be released. Satisfaction of these requirements should be ascertained by the law enforcement agency, since it is the law enforcement agency
3 The Guidelines in Appendix A are also available on the Division of Criminal Justice Internet website at www.njdcj.org. Once at the website, click at the tab "AG Guidelines," then locate "DWI Enforcement" and click on "John's Law, Potential Liability Warning - Forms & Guidelines."
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ATTORNEY GENERAL LAW ENFORCEMENT DIRECTIVE NO. 2001-5
- APPENDIX B -
GUIDELINES FOR MANDATORY 12-HOUR IMPOUNDMENT OF MOTOR VEHICLES
which authorized the impoundment. The manner and form by which satisfaction of these requirements is communicated by the law enforcement agency to its agent who impounded the vehicle are to be determined by each law enforcement agency.
Regardless of the ownership of the vehicle, the person claiming the vehicle must present the following documentation or authority.

• A valid driver's license.
  
• Proof of ownership of the vehicle or evidence of lawful authority to operate that
  vehicle.
  
• Proof of valid insurance for the vehicle.
  In addition, the person claiming the vehicle must satisfy the following criteria.
  

• The person must be able to operate the vehicle in a safe manner.
  
• The person would not be in violation of Title 39 by operating the vehicle.
  
• The person has met any other conditions for the release of the vehicle as
  established by the law enforcement agency, including but not limited to the payment of the reasonable fees for any towing and/or storage of the vehicle.
  Additionally, if the person claiming the impounded motor vehicle is not the owner or lessee the following statutory requirement must be satisfied.
  

• The person must acknowledge, in writing, receipt of the POTENTIAL LIABILITY WARNING - N.J.S.A. 39:4-50.22.
Failure of the person to comply with this statutory requirement prohibits the release of the impounded vehicle before the 12-hour period of impoundment has elapsed.
The law enforcement agency is authorized, under the provisions of N.J.S.A. 39:4-50.23(e) to retain custody of the vehicle until the fee for towing and storage is paid.
-5- 

48-Hour IDRC Scheduling Letter Information

48-Hour IDRC Scheduling Letter Information

Please notify the IDRC in writing prior to your scheduled attendance if you have a disability and will require assistance.

CLASSES are scheduled Friday – Sunday; you are to report by 6:00 pm.
FOOD is provided, as are beds, bed linens and towels. 

YOU MUST BRING the following items:
FEE ($321.00): Fee paid by CERTIFIED CHECK or MONEY ORDER ONLY, payable to Straight & Narrow, Inc. *NO Personal Checks will be accepted. 
Sleepware, change of clothes, toiletries. If you take prescription medication(s), please bring only the amount you need for the duration of the program, in your prescription bottle(s), and advise the Nurse upon screening. Change for the candy and soda machines, if desired (NOTE: some of the machines only accept quarters). 
INSTRUCTIONS: If you cannot speak English, please bring an interpreter with you. NO electronics; only cell phones which will be checked in upon your arrival. All participants will be subject to a breathalyzer. You must call to confirm your attendance at least 2 weeks prior to class date and at that time advise us of your phone number. Upon reaching the Passaic IDRC you must also advise us if you have any medical conditions, no one admitted without prior authorization. 
EMERGENCY UPDATE POSTING(s) – (Program cancellation updates due to inclement weather), visit website: www.straightandnarrowinc.org 
IT IS YOUR RESPONSIBILITY: to check the website for posting(s) the day of your scheduled program. If a program is cancelled; contact the IDRC on the following Wednesday to be rescheduled. 

source: http://www.straightandnarrowinc.org/idrc.php

IDRC Affiliation Agreement Coversheet and IDRC Affiliation Agreement

DEPARTMENT OF HUMAN SERVICES
DIVISION OF MENTAL HEALTH AND ADDICTION SERVICES INTOXICATED DRIVING PROGRAM
P.O. BOX 365
TRENTON, NJ 08625-0365 

Dear Potential Intoxicated Driver Resource Center (IDRC) Affiliated Provider: 

Enclosed are the IDRC Affiliation Agreement Coversheet and IDRC Affiliation Agreement for the July 1, 2017 - June 30, 2018 cycle to be completed for each site and level of care by interested ambulatory substance use disorder treatment providers. The coversheet provides instructions on the required attachments that must be included with your completed affiliation agreement when submitting to your county IDRC for the upcoming cycle. 

The IDRC Affiliation Agreement Coversheet and IDRC Affiliation Agreement are applicable to all interested Department of Human Services (DHS) licensed substance use disorder ambulatory treatment providers that were NOT affiliates in the July 1, 2016 through June 30, 2017 cycle, as well as for all non-DHS licensed private agencies wishing to affiliate or re-affiliate for the July 1, 2017- June 30, 2018 cycle. 

All County IDRC’s must be contacted prior to submitting materials to ensure that a complete package, including any county specific IDRC materials that may also be required and not included in these enclosures, are mailed to the appropriate address. County IDRC Directors can be contacted by accessing their information on the State Intoxicated Driving Program (IDP) website at: www.state.nj.us/humanservices/dmhas/resources/services/treatment/addictions/IDRC_Directory.pdf. Any IDRC Affiliation Agreement Coversheet and IDRC Affiliation Agreement questions should be posed to the County IDRC Director in which your ambulatory treatment site is located. Thank you. 

Sincerely, 

Andrea Connor Chief 

Enclosures 

New Jersey Is An Equal Opportunity Employer 

IDRC AFFILIATION AGREEMENT COVERSHEET INSTRUCTIONS 

•   Complete one Affiliation Agreement and IDRC Affiliation Agreement Coversheet for EACH AMBULATORY treatment site location. Be sure to complete Sections A, B, C, D, and E in their entirety.
  
•   All information submitted on the Affiliation Agreement and IDRC Affiliation Agreement Coversheet must be identical in spelling and punctuation as indicated on your license (e.g. Agency Name, Address, etc.)
  
•   Be sure to label all Affiliation Agreement attachments appropriately as defined in the IDRC Affiliation Agreement Coversheet. Unsorted/mislabeled documents may be rejected or returned.
  
•   Type or use block letters on all entries on the Affiliation Agreement and IDRC Affiliation Agreement Coversheet. Illegible documents may be rejected or returned.
  
•   All documents are to be returned to the County IDRC for review. The County IDRC will complete Section F prior to submitting to the Intoxicated Driving Program for final approval.
  
•   Additional guidance is provided in italics throughout the document.
  SECTION A - TREATMENT SITE AND CONTACT INFORMATION
  (If treatment site is licensed by the DHS, use name, spelling, and punctuation as listed on the Office of Licensing (OOL) license):
  

NEW or PRIVATE AGENCY 

Agency Name/Affiliate Provider Applicant: Treatment Site County:
Treatment Site Street 1:
Treatment Site Street 2: 

Site City:
Treatment Site Phone #:
Treatment Site Fax #:
Treatment Site E-mail:
If the site is licensed by the DHS, enter OOL License #: If the agency has a NJSAMS account, enter NJSAMS #: 

Site Zip: 

Page 2 of 12 

Name: E-Mail: 

Name: E-Mail: 

Name: E-Mail: 

Name: E-Mail: 

Treatment Site Admissions Contact Title: 

Phone #: Treatment Site Administrative Contact 1 

Title: 

Phone #: Treatment Site Administrative Contact 2 

Title: 

Phone #: Treatment Site Administrative Contact 3 

Title: Phone #: 

SECTION B - TREATMENT AGENCY INFORMATION 

NEW or PRIVATE AGENCY 

(If operating as a LLC, enter the authorized managing member. If the provider is a Sole-Proprietorship or unincorporated partnership, enter the individual signing the Affiliation Agreement.) 

Treatment Agency Executive Director Name:
Title:
E-Mail: Phone #: Address (If different from treatment site): 

If the treatment agency’s mailing address is different from site address, enter the agency address: 

Agency Street 1:
Agency Street 2:
Agency City: Agency State: Agency Zip: 

Page 3 of 12 

SECTION C - AFFILIATION LEVEL OF CARE INFORMATION 

Indicate all level(s) of care for which the treatment site is affiliating (DHS licensed agencies MUST include a copy of their OOL license for EACH level of care indicated in their submission): 

___ Assessment
___ Level I Standard Outpatient ___ Level II Intensive Outpatient ___ Level II.5 Partial Care 

SECTION D - AFFILIATION AGREEMENT ATTACHMENTS 

The following attachments MUST be included and labeled with your Affiliation Agreement when submitting to the County IDRC. Each should be labeled appropriately as Attachment 1, Attachment 2, Attachment 3, etc. 

Attachment 1: Written and signed statement by the agency’s Executive Director or owner that the agency will conform to and abide by the following as amended and supplemented by any rules adopted: 

•   N.J.S.A. 39:4-50 et seq., DUI Statute
  
•   N.J.A.C. 10:162, Intoxicated Driving Program Regulations
  
•   40A:9-22 et seq. Local Government Ethics Law
  
•   N.J.A.C. 10:161, Division of Mental Health and Addiction Services Outpatient Regulations
  
•   45:2D-1 et seq., Division of Consumer Affairs
  
•   26:2H-1 et seq., Department of Health Regulations
  Agency Name
  Executive Director or Owner Signature Date
  Print Name Title
  

NEW or PRIVATE AGENCY 

Page 4 of 12 

Attachment 2: Fee schedule for EACH Level of Care indicated in Section C, including sliding scale fee or no- fee statement and identifying other funding sources (i.e. Fee-for-service (FFS), health insurance, etc.). (See below) 

FEES AND SLIDING SCALE SCHEDULE FOR AFFILIATED LEVELS OF CARE INCLUDING: 

•   Levels of Care
  
•   Service Descriptions—Group/Individual
  
•   Rate per Service
  
•   Sliding Fee Scale*
  
•   Urine Drug Screen
  
•   Other
  Methods of Payment
  Self-pay: _____ (List payment types, e.g. MasterCard, Visa, Check, Cash, etc.) Private Insurance: _____ (List supported insurers, e.g. HBCBS, Aetna, etc.) Medicaid: _____
  Medicare: _____
  DMHAS FFS Network: _____ (List eligible programs, e.g. DUII, Drug Court, etc.) Other: _____
  *If no sliding fee scale is offered, include 10% no-charge statement signed by the Executive Director/Owner: PROVIDER AGREES TO ACCEPT UP TO 10% OF IDRC REFERRED CLIENTS AT NO COST.
  Attachment 3: Written descriptive process for EACH Level of Care seeking affiliation, including policies for:
  

•   Treatment Philosophy
  
•   Assessment Process
  
•   Treatment Planning
  
•   Self-Help
  
•   Family Treatment Resources
  
•   Discharge Planning
  
•   Continuum of Care Process
  

NEW or PRIVATE AGENCY 

Page 5 of 12 

NEW or PRIVATE AGENCY Attachment 4: Treatment site hours of operation to include Day, Evening and Weekend hours for group 

sessions for each level of care indicated. (See example below.) 

Level of Care ex. Level I ex. Level I 

Service Description Individual Session Group Session 

MON TUE 9-11 9-12 N/A 12-1:30 

WED THU 9-11 9-12 

N/A 12-1:30 

FRI SAT SUN 12-2 N/A N/A 12-1:30 9-11 N/A 

TREATMENT SITE ADMINISTRATIVE HOURS OF OPERATON 

Ex. M–F 8-5 Sat/Sun by appointment 

Attachment 5: Provider policies including written policies for Clinical Supervision, Urine Drug Screen/Oral, and/or Medication Assisted Treatment. 

Attachment 6: Current copy of Commercial liability insurance listing treatment SITE address. Attachment 7: Current copy of Professional liability insurance. 

Attachment 8: List of staff including resumes and copies of ALL current credentials/licenses. (Downloads from the State Board of Marriage and Family Therapy Examiners are not acceptable for this purpose.) 

Attachment 9 (If Applicable): Submit documented proof of education and hours of experience, including the “Proposed Plan of CADC/LCADC and Internship Agreement” for counselor interns leading to CADC or LCADC status, or to another health professional license that includes work of an alcohol and drug counseling nature within its scope of practice, without regard to changes in employment. 

Attachment 10 (optional): Agency/provider wanting to indicate additional services may indicate those services below. 

Page 6 of 12 

SECTION E - AGENCY / PROVIDER CERTIFICATION 

Initial here _______ to indicate that all documentation has been reviewed, completed, and is included in the Affiliation Agreement packet, including a site specific Affiliation Agreement, IDRC Affiliation Agreement Coversheet and Attachments 1-10 (10 optional). 

Submitted by: Printed Name: Signature: E-Mail: Phone #: 

Date Submitted to IDRC: _____/_____/_____ 

Title: 

NEW or PRIVATE AGENCY 

Fax #: 

SECTION F - FOR IDRC USE ONLY 

Initial here _______ to indicate that all documentation has been reviewed, completed, and is included in the Affiliation Agreement packet, including a signed site specific Affiliation Agreement, IDRC Affiliation Agreement Coversheet and Attachments 1-10 (10 optional) for affiliation with the County for the following level(s) of care: 

Submitted by: Printed Name: Signature: E-Mail: Phone #: 

Title: 

___ Assessment
___ Level I Standard Outpatient ___ Level II Intensive Outpatient ___ Level II.5 Partial Care 

Fax #: 

Date Submitted to IDP: _____/_____/_____ 

Page 7 of 12 

NEW or PRIVATE AGENCY 

INTOXICATED DRIVER RESOURCE CENTER TREATMENT AGENCY/PROVIDER AFFILIATION AGREEMENT 

IDRC 

Treatment Agency/Provider 

Date 

It is agreed that the above named treatment agency or provider will accept referrals from the ____________________County Intoxicated Driver Resource Center (IDRC) or the Intoxicated Driving Program (IDP) of the N.J. Department of Human Services, Division of Addiction Services for the purpose of alcohol and/or drug abuse treatment. As per the Intoxicated Program Regulations, (N.J.S.A.10:162-5.1), “ ...All approved treatment programs shall report to the Division of Addiction Services through the Division’s Alcohol and Drug Abuse Data System or any successor treatment management information system implemented by the Division”. 

The initial determination of treatment appropriateness will be made through the screening process accomplished by the IDRC or IDP. 

“Treatment appropriate” refers to those IDRC or IDP clients who may be in need of a structured intervention into their drinking and/or drug use; or care for alcohol, drug abuse or related problems. 

A treatment referral will be made by the IDRC or IDP. If from the IDRC, the Agency/Provider will communicate with the IDRC and will send the entire required forms etc. to the IDRC. If the referral is from the IDP, then the Agency/Provider will send all forms etc. to the IDP. 

The Agency/Provider will be notified of the referral via the Treatment Referral form. Clients referred to the program will be given an Agreement to Participate in Treatment form by the IDRC or IDP, and they will contact the program for an intake interview by the agreed contact date.1 

The Agency/Provider agrees to schedule the client for the intake interview within 30 days of the client’s contact of the program. 

If the client fails to make contact or appear for his appointment, the Agency/Provider will immediately inform the IDRC or IDP, as appropriate, via the Client Treatment Release form. 

When the client appears, the Agency/Provider will perform an in-depth assessment and make a determination as to the client’s appropriateness for the program. If the client is found not appropriate, the Agency/Provider agrees to immediately inform the IDRC or IDP, as appropriate, via the Client Treatment Release form, with supporting explanation. 

If the client is treatment appropriate and is accepted for treatment with the Agency/Program, the IDRC or IDP, as appropriate, will be informed via the Client Intake form. The agency agrees to make an independent evaluation of the client’s needs in treatment. A copy of the evaluation and recommendations must be sent with the Client Intake form. The information packet received from the IDRC shall be utilized. The Client 

1 Contact date-within 10 days of agreement signature. 

Page 8 of 12 

NEW or PRIVATE AGENCY Intake form and evaluation by the treatment program shall be sent to the IDRC or IDP, as appropriate, within seven (7) working days after the intake with the Records Release Authorization. The IDRC or IDP, as 

appropriate, must concur with the treatment plan prior to the start of treatment. 

The Agency/Provider agrees to inform the client of his/her specific responsibility under the treatment plan and to provide a written copy of the plan to the client. 

The Agency/Provider agrees to establish a contract with the client regarding the treatment plan. 

The client shall sign a Records Release Authorization during the intake process. The form shall be completed to allow the Intoxicated Driver Resource Center, all New Jersey courts, the Intoxicated Driving Program, the Division of Addiction Services, the Motor Vehicle Commission, the client’s attorney, and the treatment program to exchange information. A copy shall be sent the IDRC or IDP, as appropriate. 

The Agency/Provider will inform the IDRC or IDP, as appropriate, of the client’s participation in treatment on a monthly basis for the duration of treatment. Verification of active treatment participation will be by use of the monthly roster and Client Treatment Progress form to be filed by the fifteenth (15) day of each month. 

When the client is released from treatment, with approval, or if the client refuses to complete treatment, the Agency/Provider agrees to inform the IDRC or IDP, as appropriate, via the Client Treatment Release form within seven (7) days. All forms will be supplied by the IDRC or IDP, as appropriate. 

The Agency/Provider may apply whatever treatment plan is deemed necessary for each client. If the treatment plan is acceptable to the IDRC or IDP, as appropriate, the referral agency will require the client to complete that treatment. The program may also charge the client applicable fees for treatment services rendered. The IDRC or IDP will not be responsible for the client’s treatment fees. Division of Addiction Services Network Affiliated Treatment Providers may apply for funding of treatment via the Driving Under the Influence Initiative (DUII) fund, (Subchapter 10:162-10.1 through 10.4, a through e) if the client is indigent/medically indigent. 2 (When monies from the Fund are not available, the Agency/Provider shall provide treatment on a sliding scale basis or at no cost for up to 10 percent of their IDRC/IDP clients required in N.J.A.C. 10:162-6.16, b.)3 

The undersigned hereby agrees to the terms described in this document and to the Division of Addiction Services rules and regulations found in N.J.A.C. 10:162, and N.J.S.A. 39:4-50. 

The DAS-Licensed Agency/Provider agrees that all treatment will be performed or supervised by a Licensed Alcoholism or Drug Abuse Counselor (LCADC), who meets the criteria established in N.J.S.A. 45:2D et seq. and any rules adopted pursuant thereto. 

The Agency/Provider agrees to notify the IDRC or IDP, as appropriate, immediately of any changes in its fee schedule, including sliding fee schedule, and information on fee payment by health insurance and other information required by N.J.A.C. 10:162. 

The Agency/Provider agrees to adhere to professional standards of care and ethics and any applicable State and Federal laws and regulations. Further, the Agency/Provider certifies with this agreement that no principal or 

2 inserted for clarification –N.J.A.C. Subchapter 10:162-10.1 through 10.4, a through e 3 inserted for clarification - N.J.A.C. 10:162-6.16, d. 

Page 9 of 12 

NEW or PRIVATE AGENCY employee of the treatment program is in a conflict of interest situation with this County IDRC or any other 

County IDRC. 

The Agency/Provider agrees to provide the IDP and the IDRC with a written description of treatment philosophy, program requirements, and treatment modalities. 

The Agency/Provider agrees to provide the IDRC and IDP with a statement regarding its use of chemical testing as a requirement of treatment or evaluation. 

The Agency/Provider warrants that there are no real or potential conflicts of interest with respect to the IDRC or IDP and services provided. 

The Agency/Provider warrants that its facilities comply with all zoning, fire, building, health, and/or other applicable regulations. 

The Agency/Provider shall furnish the IDRC and IDP with copies of malpractice and commercial liability insurance and will hold the IDRC and IDP harmless from and against all claims, personal injury, or death sustained in connection with the delivery of services by the Agency/Provider and which result directly from any wrongful acts or omission, including negligence or malpractice, of any of its officers, directors, employees, agents, servants or independent contractors. The provision of this paragraph shall continue after the termination of this Agreement with respect to any liability, loss, expense or damage resulting from acts occurring prior to termination. 

If the client is in need of a different treatment plan, the Agency/Provider will notify the IDRC or IDP, as appropriate. The IDRC or IDP will decide the appropriate course of action. 

This agreement shall expire on the last day of June of each year, and shall not survive that date without prior written IDRC or IDP approval. The IDRC or IDP may terminate this agreement for violation of this agreement or violation of any policy, procedure, rule or regulation as prescribed in N.J.A.C. 10:162. 

The Agency/Provider may terminate this agreement by providing the IDRC, IDP with at least four (4) months written notice. 

Agency/Provider: N.J.S.A.M.S. Number 4 

Location of Program:
(if more than one location, list on reverse side) 

Mailing Address: 

4 current name of document 

Page 10 of 12 

Phone Number: Hours of Program: Days of Week: Contact Person: Cost: 

Sliding Fee Scale Available: 

Third Party Payment Available: 

Alcohol and/or Drug Testing: (may be required) 

________Yes ________No ________Yes ________No ________Yes ________No 

NEW or PRIVATE AGENCY 

List of Program Counselors with licenses, certifications, or experience, and foreign languages that will have contact with IDRC clients and identify how and in what capacity each staff member serves. (Use back of page if necessary) 

Name and qualifications of person providing clinical supervision of counselors conducting treatment for DUI clients. 

Page 11 of 12 

NEW or PRIVATE AGENCY 

Signing for the IDRC 

Signing for the Agency/Provider Name and Title (please print) 

Signing for the IDP 

Director, IDRC Date 

Date 

Chief, IDP Date 

Page 12 of 12 

source http://www.state.nj.us/humanservices/dmhas/resources/services/treatment/addictions/New_or_Private_Agency_OP_Affil_Agreemt.pdf