Urine Drug Screening Affidavit

Please correct the errors described below.

hereby understand that the Urine Screening Test is necessary and a requirement for any patient taking Narcotic Medications. I also acknowledge, as stated in the narcotic agreement, this test will be performed randomly or as needed by the physician without previous notice, regardless of my insurance coverage.

does not pay for this test, I will be responsible for the balance and promise to pay it in full. The office fee for this test is $25.00 and it will be due immediately after being notified of my insurance’s denial. .

I understand that if I refuse to sign this affidavit I will not receive any controlled substances to treat my painful condition. I also understand that by law, the sample collected will be sent to a specialty lab, which will conduct confirmations on any positive results as well as any additional screenings requested by the physician. This lab is an independent Lab and has no connection with our office; therefore they will conduct their own billing process and will submit claims to your health Insurance Company for payment. Any denials or billing questions on these confirmations should be addressed directly with the Laboratory. Our office has no knowledge or access to any billing information from any of these Laboratories.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Spanish Version: Por motivos legales el consentimiento del paciente debe estar consignado en este documento en inglés, pero si usted no tiene claridad con respecto a algo aquí relacionado, favor solicite la versión en español del mismo a nuestro personal.

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