Healthcare Delivery Form

HEALTHCARE DELIVERY FORM

Date of Request:    Patient Name:

Patient Information

Date of Birth:    Gender: Male Female Other

Insurance Information

Medical History / Current Health

Delivery Details

Type of Delivery: Home Visit Telehealth Visit Medical Supplies/Equipment Medication Delivery

Preferred Delivery Date:    Preferred Time Window:

Itemized Delivery (if applicable)

Item 1:    Quantity:    Lot/Serial #:

Item 2:    Quantity:    Lot/Serial #:

Additional items may be added on an attached sheet. If patient is unavailable at delivery time, I authorize: Leave on premises Release to designated agent

Consent, Authorizations, and Acknowledgments

By signing below I authorize the delivery of the described healthcare services, medical supplies, or medications to the recipient named herein. I acknowledge that:

• Delivery personnel will follow reasonable procedures to protect privacy and safety during delivery, but I understand that physical handling of supplies may be required.
• I have provided complete and accurate medical and allergy information and agree to notify the provider of changes prior to subsequent deliveries.
• I accept responsibility for the secure storage and appropriate use of delivered items and for notifying the provider of defects or damages within 24 hours of receipt.
• I retain the right to withdraw consent for future deliveries upon written notice; however, deliveries already scheduled may not be cancelled without applicable fees when notice is provided less than 24 hours before delivery.

I hereby certify that I am the patient or the patient’s legal representative with authority to consent. I authorize release of protected health information necessary to effectuate delivery, billing, and coordination of care to third parties involved in the delivery and fulfillment process.

I acknowledge receipt of the provider's privacy practices and understand my rights under applicable privacy laws. I authorize communication about deliveries and clinical issues to the following persons (if any):

Delivery Acceptance / Condition on Receipt

At the time of delivery I will inspect items to the extent reasonably practicable. Please indicate acceptance condition:

Items received in good condition: Yes    No

Legal Certification

I certify under penalty of law that the information provided on this Healthcare Delivery Form is true, complete, and accurate to the best of my knowledge. I understand that falsification or omission of material information may result in denial of service and may have legal consequences.

I further authorize the healthcare provider and its designated agents to take reasonable actions necessary to fulfill the delivery, including entry to the delivery location when expressly authorized above. This authorization does not waive any patient rights under applicable law.

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