Healthcare Asset Document

HEALTHCARE ASSET DOCUMENT

Patient Information

Date of Birth:    Gender:

Insurance Information

Emergency Contact

Medical History (Summary)

Asset Inventory (Items Brought or Assigned)

Instructions: List personal items, prosthetics, assistive devices, or facility property assigned to you during your episode of care. Indicate estimated value and current custodian. Facility will retain this inventory in the patient record for purposes of custody, billing, and disposition.

Serial/ID:    Condition:    Estimated Value:    Custodian:

Serial/ID:    Condition:    Estimated Value:    Custodian:

Serial/ID:    Condition:    Estimated Value:    Custodian:

Acknowledgments, Authorizations, and Liability

Custody and Ownership: I certify that the information set forth in this inventory is true and complete to the best of my knowledge. I represent whether each item listed is my personal property, device provided by the facility for my use, or facility property. The facility will treat documented items as described for purposes of custody, storage, and disposition.

Storage and Disposal: I authorize the facility to store, move, or otherwise take reasonable custodial actions with respect to items listed. If items are retained by the facility after discharge, the facility may assess reasonable storage and administrative fees. If personal property is unclaimed after 30 days following written notice to the last known address, the facility may dispose of the property in accordance with its policies. I acknowledge that the facility's liability for loss or damage to personal property is limited to circumstances involving gross negligence and is otherwise disclaimed to the fullest extent permitted by law.

Release Authorization: I authorize the facility to release listed assets to the following designated person upon presentation of acceptable identification and fulfillment of facility release procedures.

Indemnification and Billing: I agree to indemnify and hold the facility harmless for claims related to disposition of property where the facility has followed the documented instructions and reasonable verification procedures. I understand that repair or replacement of facility-owned equipment damaged while in my possession may be billed to me or my insurance in accordance with facility policy.

Privacy and Authorization

Privacy Acknowledgment: I acknowledge that records regarding my possessions while receiving care (including inventory forms) will be part of my health record and may be used and disclosed for treatment, payment, and health care operations as permitted by law. I authorize disclosure of asset-related information to third parties when necessary to effect custody transfer, billing, repair, or lawful disposal of items.

Authorization Expiration: This authorization is valid until unless earlier revoked in writing. I understand that revocation will not affect actions taken in reliance on this authorization prior to receipt of such revocation.

Revocation and Questions: I understand that I may revoke this authorization in writing at any time, except to the extent that the facility has acted in reliance on this authorization. Signing below constitutes a binding acknowledgment of the terms herein and grants the facility the authorizations described above.

Consent Confirmation: I confirm the inventory above accurately reflects items in my custody or assigned to me.

I authorize storage and disposition as described in this document.

I authorize release to the designated person identified above under the facility's verification procedures.

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