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A calm sky-blue waiting area with four mid-century modern wooden chairs, grey cushions, two framed prints centered on the wall above, and a potted plant at the left edge, representing the professional and welcoming environment at Availia TeleHelp PLLC in Spokane and Washington State.

Urinalysis ROI (Spokane Only)

Authorize your urinalysis results to be released directly to Availia from Drugscan, Absolute Drug Testing, or both. Complete before your same-day urinalysis appointment.

When and Why

Complete this form to authorize Availia to communicate directly with:

Drugscan, Absolute Drug Testing, or both regarding your urinalysis testing & results.

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This form is specifically for clients completing a urinalysis as part of services with Availia.

It allows the selected lab(s) to release your results directly to Availia and allows Availia to contact the lab on your behalf regarding scheduling, results, & other relevant matters.

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If you need to authorize a different person or agency, use the Blank ROI instead.

Availia Client Information:

Date of Birth
Month
Day
Year

Authorized Lab(s):

Authorization Details:

I authorize mutual exchange, release, & disclosure of my personal & clinical information between Availia TeleHelp PLLC and the selected urinalysis provider(s) above, using any reasonable secure method including electronic or verbal transmission, portal access, or fax. This authorization includes but is not limited to: contact information, date of birth, current medications, test scheduling & results, & any observations or communications relevant to services. This authorization is for the purpose of coordinating urinalysis testing & reporting as part of services with Availia. Information disclosed under this authorization may be protected by federal confidentiality rules (42 CFR Part 2). Federal law prohibits the recipient from making further disclosure of such information without your written consent or as otherwise permitted by law. This authorization expires one year from the date of last disclosure or external correspondence made under this authorization.

Client Acknowledgment

Availia TeleHelp PLLC and signee agree that any digital signature may serve the full legal effect and function of a handwritten signature.

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