Healthcare Substance Attestation

HEALTHCARE SUBSTANCE ATTESTATION

Purpose: This attestation documents the patient’s disclosures regarding use of alcohol, prescription medications, controlled substances and other intoxicants for the purpose of safe clinical evaluation, prescribing, procedural planning, and potential toxicology testing. The patient certifies that the information provided is true and complete to the best of their knowledge. Knowingly providing false information or concealing relevant substance use may affect medical treatment and may result in denial of services or other consequences in accordance with applicable law and facility policy.

Patient Information

Date of Birth:    Gender: Male Female Other/Prefer not to say

Insurance Information

Relevant Medical History

Substance Use Disclosure

Please indicate any substances used within the past 12 months (check all that apply) and provide details where requested.

Alcohol    Tobacco / Nicotine    Marijuana    Opioids (prescription or non-prescription)

Benzodiazepines    Stimulants (amphetamine/methamphetamine)    Cocaine    Other illicit drugs

Attestation and Certifications

1. I certify that the information I have provided in this attestation is true, complete and accurate. I understand that this information will be used by my treating clinician and facility staff to assess risks, determine appropriateness of medications and procedures, and to order drug/alcohol testing where clinically indicated.

2. I have not knowingly used any alcohol, illicit drugs, or non-prescribed controlled substances within the last hours prior to this visit/procedure unless separately disclosed to my clinician above.

3. At the time of examination or treatment I am not under the influence of substances that impair my ability to consent or to participate safely in care: I attest I am not under the influence

4. For patients assigned female at birth: I attest that I am not currently pregnant or attempting to become pregnant unless I have disclosed pregnancy status to my clinician. Not pregnant / pregnancy disclosed

Authorization for Testing and Disclosure

I authorize the collection of biological specimens (urine, blood, saliva, breath) for the limited purpose of drug and/or alcohol testing as required for my clinical care and safety. I understand that a positive result may lead to further clinical assessment, alteration of treatment, delay or cancellation of procedures, and communication of results to treating clinicians, pharmacy staff, and appropriate clinical departments.

Authorization for sample types (check all that apply): Urine Blood Saliva Breath

I understand that refusal to consent to testing or to provide specimens when required for safety or treatment may result in postponement or denial of certain services. I understand the consequences of refusal

Privacy and Duration of Authorization

I acknowledge that information disclosed on this attestation and any test results will be recorded in my medical record and disclosed internally to individuals involved in my care. Such disclosures are protected under applicable privacy laws and institutional policy. I may withdraw this authorization at any time in writing, but withdrawal will not affect actions already taken based on this authorization.

I acknowledge receipt of the facility's privacy practices regarding the use and disclosure of health information and the above-authorized testing. I acknowledge and consent

Patient Certification

I certify under penalty of law that all statements made on this attestation are true and complete. I understand that deliberate falsification may result in clinical, administrative or legal consequences.

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