UA Authorization

1258 High Street, Eugene, OR 97401

Phone 541-342-8437 | Fax 541-242-2999

Urinalysis (UA) Authorization

Name:    Date of Birth:

Center for Family Development Recovery Program utilizes urine testing in order to objectively determine whether recent drug use has occurred. Urinalysis (UA) can serve as a motivator to assist individuals in becoming drug free.

Center for Family Development requires a UA at the time of assessment, and thereafter individuals will be tested during the course of services. UA results will be utilized to further develop service recommendations. If an individual refuses to do a UA or is unable to produce the sample, it will be assumed the sample would have been positive. The integrity of UAs is an essential element of the Recovery Program. As such, UAs are monitored closely and observed as needed.

I understand that if I receive public funding or am in the DUII program, CFD must report the number of positive UAs I produce as required by the State of Oregon for the Measures and Outcomes Tracking System (MOTS). I acknowledge that dilute UAs are recorded in MOTS as positive.

UAs will be sent to the lab for analysis.

By signing below, I acknowledge that:

  • I have read this form and understand its contents.
  • I understand the information on dilute UA samples and false positive UA results.
  • If I am not carefully monitoring my liquid intake before providing a UA sample, I could provide a dilute sample.
  • If I am enrolled in CFD's DUII Program, a positive UA result without a valid prescription or a UA result of "specimen is dilute" will restart the time for my documented substance abstinence.
  • I agree to have urine specimens analyzed for purposes of determining my use of drugs and alcohol.
  • I acknowledge that I may ask for copies of my UA results in the future and that my signature acts as approval for this release.

This document is being signed by:

If you are signing as the Personal Representative, please complete the following section; otherwise, proceed to signing the form.

Full legal name of Personal Representative:

Relationship to client:

Definition of Personal Representative:
For Adults: A person with legal authority to make healthcare decisions on behalf of the adult. Supporting documentation required.
For Youth: A parent, guardian, or other person acting in the place of a parent with legal authority to make healthcare decisions on behalf of the minor child. Supporting documentation may be required.

Leave this empty:

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Signature Certificate
Document name: UA Authorization
lock iconUnique Document ID: 9a0e1c57b552e48d90533cf44cfe825289d07c4e
Timestamp Audit
May 1, 2020 1:16 pm PSTUA Authorization Uploaded by Do Not Reply - IP
June 2, 2020 4:28 pm PSTCFD Main - added by Jason Dooley - as a CC'd Recipient Ip:
March 18, 2021 2:46 pm PST Document owner has handed over this document to 2021-03-18 14:46:53 -
March 18, 2021 2:46 pm PSTCFD Main - added by Do Not Reply - as a CC'd Recipient Ip:
May 3, 2021 10:29 am PSTCFD Main - added by Do Not Reply - as a CC'd Recipient Ip: