The State of California and the County of Sacramento have authorized Breining Institute to provide Driving-Under-the-Influence (DUI) Program services through the use of online telehealth Internet technology.

Participation in the DUI Program services through online telehealth Internet technology is entirely voluntary. You are not required to participate in the DUI Program services through this telehealth option.

The telehealth ZOOM teleconferencing platform selected by Breining Institute complies with the provisions of the Health Insurance Portability and Accountability Act (HIPAA). However, using any online telehealth format may, by its nature, present a potential risk of disclosure of your personal information. If you do not wish to be exposed to this potential risk, you should not use the online telehealth format to complete your DUI program.

By completing and submitting this form, you will be voluntarily agreeing to receive and participate in DUI Program services using the online telehealth Internet technology.

Please do not complete this form until after speaking with a Breining Institute DUI Program Administrator.

If you are already familiar with the ZOOM teleconferencing platform, or do not need to participate in a tutorial, you may continue by selecting the “Next” button, below.

If you would like to become familiar with how the ZOOM teleconference platform is used, here is link to the ZOOM Video Tutorials page: ZOOM Video Tutorials

Participation in the Driving-Under-the-Influence (DUI) Program services through online telehealth Internet technology is entirely voluntary. You are not required to participate in the DUI Program services through this telehealth option.

The telehealth ZOOM teleconferencing platform selected by Breining Institute complies with the provisions of the Health Insurance Portability and Accountability Act (HIPAA). However, using any online telehealth format may, by its nature, present a potential risk of disclosure of your personal information. If you do not wish to be exposed to this potential risk, you should not use the online telehealth format to complete your DUI program.

By completing this form, you are voluntarily agreeing to receive and participate in DUI Program services using the online telehealth Internet technology.

You attest to your understanding that Federal and State laws protect the confidentiality of information relating to Breining Institute program participants. By signing below and participating in the Breining Institute DUI program activities using the online telehealth technology, you hereby consent to the disclosure of your personal information, and specifically the disclosure of your name and likeness, to the extent necessary for participation in program services provided via telehealth platforms and specifically the Zoom teleconferencing platform.

By signing below I attest to my understanding that information relating to Breining Institute program participants is protected from disclosure by Federal and State laws and regulations. I further understand that these laws and regulations prohibit my disclosing to others any information relating to any Breining Institute program participant. By signing below I indicate my agreement that:
1. I will maintain the confidentiality of all information learned and observations made by me during participation in Breining Institute program services provided via telehealth platforms and specifically information learned and observations made during the Zoom teleconferencing platform.
2. I will not photograph or record the voice or likeness of any other participant while receiving Breining Institute program services provided via telehealth platforms and specifically during any Zoom teleconference.
3. I will maintain the confidentiality of the teleconference by agreeing not to allow any person other than myself to listen to or observe any Breining Institute teleconference providing program services and specifically any Zoom teleconference.
4. I will not allow any other person to photograph or record the voice or likeness of any participant in any Breining Institute teleconference providing program services and specifically any Zoom teleconference.

By signing and submitting this Agreement:

• I am choosing to voluntarily participate in the DUI Program Services using the online telehealth Internet technology; and
• I understand that there is no assurance of confidentiality when using the online telehealth technology service due to the nature of the Internet technology.

If you are ready to submit this DUI Program telehealth services Consent / Acknowledgements form, please select the “Submit” button below, and this form will be submitted to Breining Institute.