Healthcare Toxicology Attestation

Healthcare Toxicology Attestation

Patient Information

Male Female Other Prefer not to say

Insurance / Authorization

Medical History Relevant to Toxicology

Specimen & Testing Information

Specimen Type: Urine Blood Hair Oral Fluid

Collection Observed: Observed Unobserved

Reason for Test

Pre-employment Random/Surveillance Post-accident Medical treatment Other

Attestation and Consent

I, the undersigned patient, attest that the information I have provided on this form is true and complete to the best of my knowledge. I understand that a toxicology test is being ordered for the purpose(s) indicated above and that results may be used by my treating provider, employer, licensing body, or other authorized recipients for clinical, administrative, or occupational decisions.

I certify that I have disclosed all current prescription and non‑prescription medications, herbal supplements, and recently administered medical treatments that could affect test results. I understand that failure to disclose medications or to follow specimen collection instructions may result in an inability to interpret test results or in adverse administrative action.

I understand that a positive, negative, or otherwise non‑negative test result will be documented in my medical record. I authorize release of test results and related information to the following recipient(s) as necessary for treatment, care coordination, payment, or as required by applicable policies:

I authorize the release above and understand that such disclosure may include results of controlled substance and alcohol testing. I understand that the recipient may re‑disclose information in accordance with its policies and applicable law.

I have been informed of the potential consequences of a confirmed positive test, including but not limited to clinical follow-up, treatment referral, employment or licensure implications where applicable, and that I may be offered the opportunity to provide information about legitimate use of prescribed medications prior to final interpretation.

I understand that I may revoke this authorization at any time by providing written notice to the ordering provider, except to the extent that action has already been taken in reliance on this authorization. Unless sooner revoked, this authorization will expire on the date entered below.

HIPAA / Privacy Acknowledgment

By signing below I acknowledge that I have been provided with information regarding the confidentiality of my health information. I understand that my toxicology results are protected health information and will be handled in accordance with privacy requirements, except as authorized above or as required by law.

Patient Declaration

I acknowledge that I have had the opportunity to ask questions regarding this test and the information above. I understand my rights with respect to this testing, including the right to consult with the ordering clinician prior to or after testing.

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