Healthcare BIPAP Loaner Agreement

Healthcare BIPAP Loaner Agreement

Parties and Agreement Date

Facility Name:

Patient Name:

Agreement Date:

Patient Information

Insurance Information

Device Issued

Device Type:

Manufacturer:    Model:

Serial Number:

Loan Start Date:    Expected Return Date:    Authorization Expiration:

Loan Terms and Charges

The facility loans the device to the patient for the period set forth above. The patient accepts temporary custody and possession of the device and agrees to comply with the terms below. The patient acknowledges that title remains with the facility and that the device must be returned in the same condition as received, reasonable wear and tear excepted.

Loan Fee (if any): $    Replacement Cost (approx.): $

Patient is responsible for costs not covered by insurance including, but not limited to, loss, theft, damage due to misuse, and negligent repair. The patient authorizes the facility to bill patient or patient's insurance for charges related to the loan as permitted by law.

Use, Training, Cleaning and Maintenance

The patient affirms receipt of device orientation and operational training: Training provided    Date of Training:

Patient must follow all manufacturer and facility instructions for cleaning and infection control. Facilities recommend cleaning of reusable components and replacement of disposable components as directed. Patient shall not attempt internal repairs or modify the device. Any required maintenance must be performed by authorized personnel.

Repairs, Loss and Damage

Patient must notify the facility immediately of any malfunction, damage, or loss. The facility will assess device and determine whether repair or replacement is required. The patient may be charged for repair or replacement where damage is due to misuse, negligence, or failure to follow instructions.

Late return fee (if not authorized): $

Privacy, Consent and Authorization

By signing below, the patient authorizes the facility to disclose necessary device and clinical information to insurance carriers and to facility personnel for billing, care coordination, and device servicing. The patient acknowledges receipt of the facility's privacy practices and consents to release of records as necessary for billing and device servicing.

I acknowledge receipt of the facility's privacy notice and consent to necessary disclosures for billing and device servicing.

This authorization is valid through: . Patient may revoke this authorization in writing, subject to any disclosures already made.

Acknowledgment and Agreement

I, the undersigned, acknowledge receipt of the BIPAP device and listed accessories in the condition described above. I have been instructed in proper use, maintenance, and cleaning, and I understand my responsibilities under this Loaner Agreement. I accept financial responsibility for charges not covered by insurance as described herein.

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