I, _____________________________, do hereby give my consent to United Hospital Services, LLC (“Company”) and any medical testing laboratory or clinic designated by the Company to perform appropriate tests or examinations on me, as a prerequisite to hiring, including, but not limited to, urine or blood testing for illegal, controlled, or unauthorized substances or alcohol, as permitted by law. I also agree to take any physical examinations or medical tests now or at a later time that the Company may require in the future for the health or safety of its employees, including but not limited to testing for illegal, controlled, or unauthorized substances or alcohol. I also give my permission to any doctor, nurse, technician or medical clinic, which administers tests or examinations to release the results of any tests or examinations to the Company. I further authorize any prior employer, doctor, hospital, clinic, laboratory, or other health facility which has been involved with any care, treatment or diagnosis of my physical condition to furnish the Company with a complete transcript of any and all of my medical records as may be necessary to confirm or supplement information I may be asked to provide prior to or after taking a medical test or examination.

I understand that a determination by a medical testing laboratory or clinic designated by the Company may result in a decision not to hire me or in the termination of employment if I have been hired, if any illegal, controlled or unauthorized substance or alcohol is present in my body. It may also result in a determination that I am not medically qualified to drive a commercial motor vehicle.

I agree to release and hold harmless the Company, its agents and employees from any and all liability and damages resulting or arising from any medical test or physical examination or the Company’s reliance on same, or in connection with any action taken by the Company in reliance upon the test or examination results, or from the release of the results of any such test or examination.

In the event I am not hired due to a positive test result, I hereby authorize the Company to release such information to the Indiana Department of Employment and Training Services if I was referred to the Company by such Department or to any other referral agency if I was referred to the Company by such agency.