Healthcare Delivery Ticket

HEALTHCARE DELIVERY TICKET

Provider and Ticket Information

Provider Name:    Ticket No.:

Delivery Date:    Delivery Time:

Patient Information

Date of Birth:    Gender:

Phone:    Emergency Contact:    Relation:

Emergency Phone:

Insurance Information

Policy Number:    Group Number:

Medical History (Summary)

Delivery Details — Items Dispensed

Complete description for each delivered item. Countersigned receipt indicates patient (or authorized representative) has received items in good condition unless noted.

Delivery Verification & Legal Acknowledgments

By checking the boxes below and signing this Delivery Ticket, the undersigned confirms the following representations and authorizations. The undersigned acknowledges that receipt of the listed items constitutes acceptance unless a defect or discrepancy is noted in writing at the time of delivery.

Controlled substance included in delivery (if checked, ID was presented and documented).     Patient/representative identification verified by delivery agent.

Delivery Method:    In person    Curbside    Drop-off (no signature obtained at time)

HIPAA and Release Authorization: I authorize the release of delivery information and limited health information necessary to confirm delivery to the listed emergency contact and to my caregiver(s). I understand I may revoke this authorization in writing, except to the extent action has already been taken in reliance on it. This authorization does not permit broader release of medical records beyond information necessary to effect delivery.

Authorization Expiration:    If left blank, authorization is effective only for this delivery event.

Return and Liability Notice: Provider is responsible for delivering items as described. Claims for missing or damaged items must be asserted on this ticket at time of delivery or within 24 hours. Provider's liability for loss or damage is limited to replacement of delivered items or refund of charges for those items, except where otherwise required by law.

Acknowledgment and Consent to Release

I acknowledge that I have received the items listed above and that the provider has explained any necessary handling, administration, and storage instructions. I understand my right to ask questions and to refuse any item. By signing below I authorize the provider to leave future deliveries as indicated and to communicate delivery status with the emergency contact named on this ticket unless I notify the provider otherwise in writing.

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