Acknowledgment, Privacy & HIPAA

This document constitutes a legally binding authorization and acknowledgment between the undersigned commercial motor vehicle driver (“Driver”) and RoadSafe DOT Medical Exams, LLC and its certified medical examiner(s) (“Provider”).

Purpose of Examination

The Driver voluntarily presents for a Department of Transportation (DOT) medical examination conducted in accordance with applicable federal regulations, including 49 CFR §391.41 et seq., and applicable guidance issued by the Federal Motor Carrier Safety Administration (FMCSA).

The DOT examination is a regulatory fitness-for-duty evaluation required for commercial driving. It is not a comprehensive physical examination, not a substitute for primary care, and not intended to diagnose, treat, or manage medical conditions beyond determining medical qualification under federal standards.

No Guarantee of Certification

The Driver understands and acknowledges:

Certification is not guaranteed.
The determination of medical qualification is made solely in accordance with federal regulations and the independent medical judgment of the certified medical examiner.
The Provider has no authority to waive or alter federal standards.
Employment decisions are made by the employer and are not controlled by the Provider.

Regulatory Reporting and Mandatory Disclosure

The Driver understands that the Provider is required by federal law to:

Document examination findings.
Issue a Medical Examiner’s Certificate, when appropriate.
Report medical certification determinations to FMCSA and/or applicable state agencies.
Maintain required records for federally mandated retention periods.

The Driver expressly authorizes the Provider to release the following, as required by law or regulation:

Medical qualification determination (qualified, qualified with restrictions, temporarily disqualified, or disqualified).
Certification expiration date.
Required regulatory documentation.
Information mandated for reporting to FMCSA, state licensing agencies, or other governmental authorities.

The Driver understands that regulatory reporting required by law cannot be revoked.

Employer Disclosure Authorization (Limited Scope)

The Driver authorizes release to the identified employer or prospective employer of:

Medical qualification status.
Certification expiration date.
Any work-related restrictions required under DOT regulations.

No detailed medical diagnoses, treatment information, or unrelated medical history will be disclosed to the employer without separate written authorization, unless required by law.

Driver Representations and Responsibilities

The Driver affirms and represents that:

All medical history provided is complete and truthful to the best of their knowledge.
Failure to disclose or misrepresentation of medical information may result in denial, suspension, or revocation of certification.
The Driver is solely responsible for ongoing medical care and management of personal health conditions.
The Driver understands that medical conditions may affect certification status.

Limitation of Liability

To the fullest extent permitted under the laws of the State of New Jersey and the State of New York:

The Provider shall not be liable for employment consequences arising from a medical qualification determination made in good faith and in accordance with applicable federal regulations.
The Provider shall not be liable for regulatory reporting performed as required by law.
Nothing in this Agreement limits liability for gross negligence, willful misconduct, or violations of applicable law.
Nothing herein waives rights that cannot legally be waived under NJ or NY law.

The Driver acknowledges that disagreement with a certification decision does not constitute negligence.

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HIPAA Acknowledgment and Privacy Practices

The Provider complies with the Health Insurance Portability and Accountability Act (HIPAA) and applicable state privacy laws, including more stringent provisions under New York and New Jersey law where applicable.

Protected Health Information (PHI) may be used or disclosed:

For determination of DOT medical qualification.
For regulatory reporting required by federal or state law.
For health care operations and record retention compliance.
As otherwise permitted or required by law.

The Driver acknowledges receipt of, or access to, the Notice of Privacy Practices.

Right to Access and Amendment

The Driver has the right to:

Request access to examination records.
Request amendment of inaccurate information.
Request an accounting of disclosures, as permitted by law.

Revocation

This authorization may be revoked in writing at any time, except:

To the extent action has already been taken in reliance upon it.
Where disclosure is required by law or federal regulation.
Where reporting obligations to FMCSA or state agencies apply.

Severability

If any provision of this Agreement is determined to be invalid or unenforceable under applicable NJ or NY law, the remaining provisions shall remain in full force and effect.

Governing Law

This Agreement shall be governed by and interpreted in accordance with the laws of the State in which the examination is performed (New Jersey or New York), without regard to conflict-of-law principles.

Acknowledgment

By signing below, the Driver acknowledges that:

They have read this document in its entirety.
They understand the regulatory nature and limitations of the DOT examination.
They have had the opportunity to ask questions.
They voluntarily agree to the terms stated herein.