This letter serves as formal authorization for RoadSafe DOT Medical Exams, LLC to release and/or discuss the details of the DOT examination for the driver identified below. I request that this information be provided to the Federal Motor Carrier Safety Administration, the Division of Motor Vehicles for my licensed state, and the authorized employer specified below.

MEDICAL HOLD HARMLESS AGREEMENT

This Agreement is made and entered into by and between the undersigned provider and patient, collectively referred to as the "Parties."

Purpose of Agreement

The patient is voluntarily undergoing a Department of Transportation (DOT) physical examination, which is intended to assess physical and medical fitness for commercial driving per DOT regulations.

Release of Liability

The patient acknowledges that the DOT physical exam is based on medical evaluation criteria established by federal regulations. The patient agrees to hold the healthcare provider, its employees, and affiliates harmless from any liability, damages, or claims arising from the medical examination, except in cases of proven negligence or misconduct.

No Guarantee of Certification

The provider does not guarantee that the patient will be certified to meet DOT medical fitness standards. The final determination of certification eligibility is based on the provider’s medical judgment and applicable regulations.

Assumption of Risk

The patient understands that all medical evaluations carry potential risks, including but not limited to medical findings that may impact the ability to receive certification.

Agreement to Indemnify

The patient agrees to indemnify and defend the healthcare provider from any claims, legal fees, or actions arising from the DOT physical examination, except in cases of proven negligence or violation of applicable laws.

Authorization and Acknowledgment

By signing this Agreement, the Parties acknowledge that they have read, understood, and voluntarily accept the terms stated herein.