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ST. LUCIE COUNTY DRUG LAB AUTHORIZATION FOR RELEASE OF INFORMATION

First and Last Name:

DOB:

Social Security Number:
(The purpose for collecting the SS# is for the protection and confidential handling of your protected health information and is imperative for the performance of our duties and responsibilities pursuant to The Health Insurance Portability and Accountability Act of 1996.)

Name of agency or business that may receive my protected health information:
 

The purpose/use of the information is:
(Drug Tests and/or Medications Update and/or Agency Update)

(If Applicable) Specific information or dates to be released is:

Please enter your initials for the items below.

1.  I UNDERSTAND THAT I MUST PROVIDE AT LEAST HALF (1/2) OF A SAMPLE CUP OF URINE SO A CONFIRMATION TEST CAN BE DONE IF REQUESTED BY ME.

2.  Permission is hereby given to St Lucie County Drug Lab to release information including drug test results, CCF, medication lists and any other information contained in the records for the above‐referenced client.

3.  I understand that this authorization for release of information shall be effective the date of signature and expire one year from the date of signature or at the time the court case, program participation or DCF action are concluded.

4.  I also understand that I may revoke this consent or authorization at any time, providing I notify the program in writing to this effect. I understand that revocation has no effect on action previously taken and I understand St Lucie County Drug Lab will not be held liable for any information released prior to my revocation.

5.  I hereby release St Lucie County Drug Lab and its employees from any and all liability that may arise from the release of information as I have directed.

READ AND SIGN BELOW
 I acknowledge that I have given my informed consent to the SLC Drug Lab to sample my urine for the detection of mood altering chemicals.
 I understand that this is an observed urine collection by a same-sex collector (unless otherwise indicated).
I understand that I must provide at least a half of a cup of urine in order for the sample to be accepted for testing and I will remain at the lab to provide another larger urine sample if requested by lab staff.
 I certify that I will not alter or substitute the sample in anyway and I understand that to do so is a first- degree misdemeanor.
 I understand that if I disagree with the results, I may request the sample be sent to Medtox Clinical Laboratory or Cordant Forensic Solutions (Norchem Drug Testing) for the purpose of confirming the test at my own expense. (All positive samples are stored for 30 days; there must be at least half a cup of urine to be able to send for a confirmation test).
 I understand that any information released or obtained via this authorization is prohibited from further disclosure without my written permission, subpoena or by court order. I understand results can only be released to the requesting agency, or by subpoena or court order.
 I knowingly consent to this drug screen and hold the Drug Screening Lab and the collection facility harmless, being assured of proper performance of this procedure.
 I understand that payment must be made at the time the test is taken or the result will not be released.
 The Client will not use prescription drugs without a valid prescription and must disclose to the supervising Program prior to taking any medication(s).
 The Client must disclose all over the counter medications that the Client takes prior to taking the medication(s).
 The Client will not consume products containing alcohol, dextromethorphan, pseudoephedrine, poppy seeds, diet pills, protein powder, energy drinks or any substance that is designed to have an effect on their urinalysis.
 The Client is also prohibited from consuming synthetic cannabis, such as SPICE, DREAM, or any form of herbal smoking blends.

Client Email Address:

Client Phone Number:  

Sign Below. Please hit 'Accept Signature' before hitting 'Complete Form.'