Healthcare Substance Abuse Testing Form

HEALTHCARE SUBSTANCE ABUSE TESTING FORM

Patient Information

Date of Birth:    Gender:

Phone:    Email:

Insurance Information

Policy Number:    Group Number:

Reason for Testing & Specimen Collection

Reason for test (check all applicable):

Pre-employment Random Reasonable suspicion Post-accident Follow-up

Other (specify):

Type(s) of test requested (check all applicable):

Urine Saliva Hair Blood Breathalyzer

Other specimen type:

Specimen ID / Accession #:    Collection Date:    Collection Time:

Observed collection required: Yes   Observed by same sex as patient: Yes

Collector comments / noted irregularities:

Medical History Relevant to Testing

Consent, Authorization & Notices

I, the undersigned, authorize the collection of the specimen(s) identified above for the purpose of substance abuse testing. I understand that specimens will be tested for drugs and/or alcohol using accepted laboratory methods, and that confirmatory testing will be conducted for any preliminary positive result. I consent to necessary steps to ensure chain of custody, including observed collection when required.

I understand that a Medical Review Officer (MRO) will review any confirmed positive result and will make reasonable efforts to contact me to discuss legitimate medical explanations, including prescription medication use. I agree to cooperate with the MRO and to provide requested documentation regarding prescriptions or medical conditions that may affect test results.

I authorize release of my test results and related information as indicated below. I understand that my results will be treated as confidential medical information and will be released only pursuant to this authorization, to those with a medical need to know, or as required by law.

Release results to (check all applicable):
Employer/Designated Employer Representative Healthcare Provider Insurance Carrier

Release to other (name/organization):

This authorization is valid until: . If no date is provided, this authorization remains in effect for one year from the date of my signature below unless revoked earlier in writing.

I understand that I may withdraw this authorization at any time by providing written notice to the organization identified above, except to the extent that action has already been taken in reliance on this authorization. Withdrawal of authorization will not affect disclosures made prior to the receipt of the withdrawal.

Consequences of refusal or failure to cooperate: refusal to provide a specimen or to cooperate with required collection procedures may result in adverse administrative or employment action consistent with applicable policies, and may be treated as a positive test result by the requesting entity.

HIPAA and privacy acknowledgment: I acknowledge that I have been informed of privacy protections that apply to my health information and that my substance abuse testing results will be treated in accordance with applicable privacy laws. I authorize the use and disclosure of my protected health information as described above.

Patient certifications (check to acknowledge):

I consent to the requested substance abuse testing and procedures.
I understand that an MRO may contact me to clarify results and I will cooperate.
I understand how my test results may be used and released as authorized above.
I acknowledge receipt of applicable privacy practices relating to this testing.

Chain of Custody Log (for collector use)

Time/Date transferred to laboratory:    Carrier/Transporter:

Lab accession received by:    Date/time:

Acknowledgment and Signature

By signing below I certify that I have read and understand the information on this form, that the information I have provided is true and accurate to the best of my knowledge, and that I consent to the collection, testing, and release of my specimen(s) as specified above.

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