I, ____________________________________________, understand that a drug/alcohol screen is a prerequisite for employment and/or truck driver certification. I also understand that it is due to the Employer’s interest in selecting the best available candidates for employment and/or truck driver certification and providing a safe and productive workplace that the Employer has chosen to include the urine testing of drugs as a mandatory part of the pre-em-ployment and/or truck driver certification process.

A drug screen may be required at pre-employment, at random, for reasonable cause, post-accident, return to duty, follow-up testing, and according to the Employer’s policy. A drug screen may also be performed for personal reasons.

I understand that these are done under stringent laboratory conditions in order to ensure accuracy. I understand the testing will be done for some prescription and non-prescription medications as well as illegal street drugs (DOT drug screens are limited to testing for five drugs).

I have read the foregoing information and understand it completely. I acknowledge that (a) GoNow Doctors may submit my sample for further testing to a lab chosen by GoNow Doctors, (b) the laboratory may release any and all information concerning these results to the appropriate medical review office, if so mandated, or to the designated representative in other circumstances, and (c) I am not under the influence of any substance that would prevent me from understanding the above waiver and release.

This is to certify that I understand that these drug/alcohol screen results, and or copies of my medical records or portions thereof, or copies of diagnostic reports made by GoNow will go to:

C of C# ____________________________________

Collectors Signature__________________________

Fed Ex UPS Courier Airbill #_____________________

For purposes of this document, the term “Employer “ means the company ordering the drug screen, and the term “GoNow Doctors” means the entity performing the drug screen.

_________________________________________________________________________________________________PATIENT NAME DOB AGE SEX PHONE NUMBER

_________________________________________________________________________________________________ADDRESS CITY STATE ZIP SOCIAL SECURITY NUMBER

DRUG SCREEN ACKNOWLEDGEMENT

Disclaimer: The Health Care Insurance Portability & Accountability Act of 1996 (HIPPA) describes the handling of confidential protected care informa-

tion (PHI) as it appears in treatment documents. The Federal and State Drug Free Workplace Acts’ drug and alcohol results are port of search and

seizure documents and are not considered PHI. Nevertheless, GoNow Doctors will maintain confidentiality for all testing results and disclose them only

to the employee, and designated representative, the employer, and the appropriate government agencies that have the need to know under the act.

Employer NameSigned_____________________ Date_____________Witness____________________ Date_____________

Type of Screening: Random Pre-employment Post- Accident Observed

Re-Test Reasonable Suspicion Periodic Other DOT Non - DOT

REVISED 03/2016