Legal Drug Use Statement

LEGAL DRUG USE STATEMENT

This Legal Drug Use Statement is entered into as of Date: by Declarant Name: (hereinafter "Declarant") and Recipient Name: (hereinafter "Recipient").

RECITALS

WHEREAS, Declarant has prescribed medications and/or lawfully uses substances pursuant to a valid prescription or other lawful authorization and seeks to disclose the nature of such lawful use to Recipient for the limited purposes described below; and

WHEREAS, Recipient requires a written statement documenting Declarant's authorized drug use in order to evaluate safety, workplace accommodation, provision of services, or compliance with applicable policies; and

WHEREAS, the parties wish to set forth their agreement regarding disclosure, confidentiality, testing, and the legal effect of such disclosures.

NOW THEREFORE, in consideration of the mutual covenants contained herein and other good and valuable consideration, the receipt and sufficiency of which are acknowledged, the parties agree as follows:

1. DEFINITIONS

For purposes of this Statement, the following terms have the meanings set forth below: (a) "Authorized Use" means the use of a medication or substance by Declarant pursuant to a valid prescription or lawful medical direction; (b) "Confidential Medical Information" means records, prescriptions, dosage, treating practitioner communications, and other clinical information relating to Authorized Use.

2. DECLARANT REPRESENTATIONS AND DISCLOSURES

Declarant represents and warrants the following to Recipient and acknowledges that such representations are material to Recipient's reliance:

2.1 Identity and Contact. Declarant's Date of Birth: . Declarant Address:

2.2 Disclosure of Authorized Medications. Declarant hereby discloses the following medications and controlled substances taken pursuant to medical authorization and relevant dosage/schedule:

2.3 Prescription Dates. First Issue Date: ; Expected Duration or Renewal: .

3. SCOPE OF AUTHORIZED USE

Declarant affirms that all substances disclosed above are being used in a manner consistent with the prescribing practitioner's instructions and applicable law. Declarant shall not consume any illicit substances or otherwise use any non-prescribed drugs in a manner that may impair performance or safety in contexts material to Recipient's interests.

4. TESTING, RELEASE, AND CONSENT

4.1 Consent to Testing. Declarant hereby provides informed consent to reasonable medical or toxicological testing to verify the presence, level, or absence of substances where such testing is limited to the purposes set forth in this Statement and is conducted in accordance with applicable law. Declarant expressly: Consent to Testing: .

4.2 Release of Medical Information. Declarant authorizes prescribing practitioners and laboratories to disclose Confidential Medical Information to Recipient and its designated agents to the extent necessary to verify Authorized Use or to consider reasonable accommodations. This authorization is limited to the information reasonably necessary for those purposes and shall expire upon written revocation, except as needed to validate historical disclosures.

5. CONFIDENTIALITY

Recipient agrees to treat all Confidential Medical Information as confidential and to limit disclosure to those employees or agents who have a need to know for legitimate business, safety, or accommodation purposes. Recipient will maintain appropriate administrative, technical, and physical safeguards to protect such information and will not disclose Confidential Medical Information except as required by law or with Declarant's written consent.

6. PROHIBITED CONDUCT AND REMEDIES

Declarant acknowledges that any material misrepresentation, failure to disclose prescribed controlled substances, or unlawful drug use that materially affects Recipient's interests may constitute grounds for disciplinary action, denial of services, or other remedies permitted by law or contract. Recipient's exercise of remedies shall be consistent with applicable law and any contractual rights.

7. NOTICES

Any notice required or permitted under this Statement shall be in writing and delivered to the addresses set forth below by hand delivery, certified mail, or other reliable means.

8. AMENDMENT; WAIVER

Any amendment to this Statement must be in writing and executed by both parties. No waiver of any provision shall be effective unless in writing and signed by the waiving party. A waiver of any breach shall not constitute a waiver of subsequent breaches.

9. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Statement shall be governed by and construed in accordance with the laws of State or Jurisdiction: without regard to conflict of laws principles. This Statement constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior agreements and understandings, whether written or oral. If any provision of this Statement is determined to be invalid or unenforceable, the remaining provisions shall remain in full force and effect.

10. MISCELLANEOUS

10.1 Counterparts. This Statement may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument. 10.2 Construction. Headings are for convenience only and shall not affect interpretation. 10.3 Survival. Provisions relating to confidentiality, representations, and remedies survive termination or expiration of this Statement.

CERTIFICATION

Declarant certifies under penalty of perjury that the foregoing statements and disclosures are true and complete to the best of Declarant's knowledge. Declarant acknowledges that knowingly making a false statement in this document may expose Declarant to civil or criminal penalties.

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