A Workforce of Dedicated Health Care Professionals

Drug Screen Release Form

Drug Screen Release Form
Drug Test Authorization Permission Form
acknowledge that I have been advised that I may be required to submit to a drug screen test as part of the Drug And Alcohol Abuse policy of Samaritan Services, Inc. Such drug test may be a requirement of the company's pre-employment background check program or part of the company's random drug testing program.

I further understand that the Drug And Alcohol Abuse policy prohibits the presence of illicit substances in the systems of its employees while on the job. A confirmed positive test is a violation of this policy. Additionally, a refusal to test, failure to submit adequate urine for test, or adulterated sample, constitutes a positive test.
I further understand that this analysis will be held in confidence except as otherwise necessary to carry out the terms and objectives of this policy.

I understand that it is my responsibility prior to the drug testing to inform Samaritan Services, Inc. of any medication, prescribed or non-prescribed, that I may be taking and/or have taken within the last 60 days prior to the testing.

I consent to the release of the results of any drug test to authorized representatives of Samaritan Services or contracted vendor for appropriate review.

I release Samaritan Services, HR Screening Services, its affiliates, Officers, employees and any person affiliated with the testing from any claims, losses, damages or other liabilities due to any acts, omissions or negligence arising from or related to such testing.

I acknowledge that he Drug and Alcohol Policy of Samaritan Services is to have a drug free environment. I consent freely and voluntarily to a drug test under the ii .1 circumstances described above along with all the terms and conditions of the Drug and Alcohol Policy. I also understand that although I may not agree with the Drug and Alcohol Policy of Samaritan Services, Inc, failure to acknowledge the policy with my signature below may prohibit my employment with Samaritan Services, Inc. A photocopy of this authorization shall be deemed an original and shall be accepted as such by every person.