Healthcare Bio-One Cleanup Form

Healthcare Bio-One Cleanup Form

Patient Name:   Patient ID / MRN:

Patient Information

Month:   Day:   Year:

Male    Female    Other / Prefer not to say

Insurance / Billing Information

Medical History

Incident Details / Location

Incident Date: Month Day Year

Bloodborne fluids    Other bodily fluids    Sharps / needles    Chemical contamination    Other (specify below)

Cleanup Scope & Procedures Performed

The undersigned authorizes qualified personnel to perform necessary biohazard remediation including removal of contaminated materials, disinfection with appropriate EPA-registered agents, containment, and regulated medical waste disposal. Specific tasks completed (check all that apply):

Contaminated material removal    Surface disinfection    Decontamination of furnishings    Carpet and upholstery cleaning

Regulated medical waste removal and disposal    Transport of contaminated materials    Other (describe below)

Risk Acknowledgment, Authorization & Payment

By signing below, I authorize the cleanup operations described above at the specified location. I acknowledge that biohazard remediation inherently involves risk of damage to certain materials and that the remediation performed is limited to the scope identified in this form. I understand that the cleanup contractor will exercise reasonable care and apply industry-standard methods, but cannot warrant complete restoration of porous or otherwise compromised materials.

I authorize access to the premises and consent to removal and disposal of regulated medical waste. I release and hold harmless cleanup personnel for claims directly resulting from known hazards disclosed on this form, except for willful misconduct or gross negligence. I further authorize billing to the insurance identified above and acknowledge that I remain financially responsible for any portion not covered by insurance.

This authorization will expire on: Month Day Year

HIPAA / Privacy Acknowledgment

I acknowledge that personal health information may be necessary to assess risk and to coordinate cleanup and disposal. I authorize limited disclosure of my health information to personnel necessary to perform remediation and to my insurer for billing purposes. This authorization is voluntary and may be revoked in writing except to the extent action has already been taken in reliance on it.

I acknowledge and consent to the limited use and disclosure of my protected health information as described above.

Additional Notes / Observations (for staff)

Certification

I certify under penalty of perjury that the information provided on this form is true, accurate, and complete to the best of my knowledge. I understand the scope of authorized remediation, agree to the terms stated herein, and authorize the cleanup provider to proceed.

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