Healthcare Oral Fluid Testing Form

HEALTHCARE ORAL FLUID TESTING FORM

Patient Information

Insurance / Billing (if applicable)

Test Details / Authorization

Purpose of Test (select all that apply):
Pre-employment Random Screening Post-accident Reasonable Suspicion Return-to-duty / Follow-up

Test(s) to be performed:

I authorize collection of an oral fluid specimen and laboratory analysis for substances as indicated above. I further authorize the release of test results and relevant medical information to the recipient named above for purposes related to employment, treatment, or recordkeeping. This authorization includes disclosure of test results, chain of custody documentation, and notes regarding specimen collection and observed behavior.

Specimen Collection Details (to be completed at collection)

Observations at collection (select all that apply):
Refused to provide Difficulty collecting adequate specimen Signs of tampering Visible oral injury or bleeding

Medical History Relevant to Testing

Donor Instructions & Acknowledgements

I acknowledge that the collector instructed me on proper specimen provision. I confirm that immediately prior to collection I:
Did not eat in the preceding 10 minutes Did not drink in the preceding 10 minutes Did not smoke or use oral tobacco in the preceding 10 minutes Did not use mouthwash or oral hygiene products in the preceding 10 minutes

I understand that failure to follow collection instructions, providing an insufficient specimen, or attempting to adulterate or substitute the specimen may result in a report of refusal or invalid test and may have employment or treatment consequences. I understand that I may withdraw consent at any time prior to specimen collection by notifying the collector.

Authorization to Release Protected Health Information (PHI)

By signing below I authorize the laboratory, medical review officer, and testing facility to disclose the results of any oral fluid drug or alcohol testing, supporting documentation, and related health information to the recipient named above. This authorization is specific to the purposes indicated on this form and does not authorize unrelated disclosures. I understand that information disclosed pursuant to this authorization may be re-disclosed by the recipient and may no longer be protected by federal privacy rules.

Rights, Limitations and Dispute Procedures

I understand my rights to request a split-specimen or confirmatory testing as provided by applicable policies governing the testing program. If a confirmatory test is required, I understand how and where to obtain that test and that chain-of-custody requirements must be followed. I understand that laboratory confirmation methods shall be used to report definitive results. I further understand the consequences applicable under the requesting party's policy for positive, negative, or invalid test results.

Chain of Custody / Laboratory Use (for collector and lab staff)

Acknowledgement and Consent

By signing below I certify under penalty of law that the information I have provided on this form is true and accurate to the best of my knowledge. I consent to collection, testing, and release of my oral fluid specimen as described above. I acknowledge that I have been informed of the testing procedures, possible risks, and my rights regarding confirmation testing and access to results.

I understand that this authorization will remain in effect until the authorization expiration date specified above or until revoked in writing prior to collection. I understand that revocation will not apply to information already released in reliance on this authorization.

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