Non-DOT Drug Test Consent & HIPAA Release

1. Donor Information

First name *

Last name *

Date of birth *

Phone *

Email *

Address *

Upload government-issued photo ID *

2. Reason for Testing *

3. HIPAA Authorization to Release Results

I authorize Reddy LabSolutions LLC to release my drug and alcohol test results to the person or organization designated below. This authorization is voluntary, applies only to the results of this collection, and may be revoked in writing at any time except to the extent action has already been taken in reliance on it.

Designated person / organization *

Relationship (officer, employer, attorney, etc.) *

Their email

Their fax

I authorize the release of my results to the designated person above.I would also like my results sent to an additional person or organization.

4. Consent & Acknowledgments *

I voluntarily consent to provide a specimen for drug and/or alcohol testing.I understand this collection follows strict chain-of-custody standards and that observed collections are required for probation testing.I understand my health information is protected under HIPAA and will only be released as authorized above.I understand that tampering with, substituting, diluting, or adulterating a specimen will be reported as Refusal to Test / Adulterated and is non-refundable.

5. Signature

Type your full legal name as signature *

Date *

Payment is required after you submit this form to secure your collection.