Controlled Substance UDS Screening Consent Form

As part of your treatment involving controlled substances, it is the policy of Austin Mind and Behavioral Health to conduct periodic urine drug screenings (UDS) to ensure safe and appropriate use of prescribed medications.

Please read and sign the following consent:

1. Purpose: I understand that urine drug screening is a part of my treatment plan to monitor compliance with prescribed medications and to ensure my safety.
2. Frequency: I acknowledge that UDS may be requested randomly, routinely, or based on clinical judgment, without prior notice.
3. Compliance: I agree to provide a urine sample when requested. Failure to comply may result in changes to my treatment plan, including discontinuation of controlled substance prescriptions.
4. Substances Tested: I understand that the screening will test for a range of substances including, but not limited to, prescribed medications, illicit drugs, and non-prescribed controlled substances.
5. Results: I understand that the results of my drug screening will be discussed with me and become part of my confidential medical record. Abnormal or inconsistent results may lead to clinical consequences including tapering or discontinuation of medications.
6. Confidentiality: I understand that all test results will be kept confidential and used only for clinical decision-making purposes within the scope of my treatment at Austin Mind and Behavioral Health.
7. Fee: I understand that the UDS screening is not covered by insurance and will cost $25.00, which will be collected at the time of service.

Patient Acknowledgment and Consent

I have read and understand the above information. I consent to urine drug screening as part of my treatment with controlled substances at Austin Mind and Behavioral Health.