Healthcare Heat Pump Form

HEALTHCARE HEAT PUMP FORM

Request Information

Date of Request:

Patient Information

Date of Birth:    Gender:

Primary Phone:    Email:

Relationship:    Phone:

Insurance & Billing

Policy Number:    Group Number:

Subscriber DOB:

Medical History & Indication for Heat Pump

Please identify the medical conditions that support the need for a household heat pump device (select all that apply):

Chronic obstructive pulmonary disease (COPD)
Asthma with heat sensitivity
Cardiovascular condition affected by temperature extremes
Immunocompromised status
Neuromuscular disorder with thermoregulatory impairment
Other (describe below)

Physician / Clinician Statement of Medical Necessity

Clinic or Practice:    Contact Phone:

Estimated duration patient requires heat pump:

Installation Details & Site Assessment

Type of Heat Pump Requested: Ducted system Mini-split (wall/ceiling units) Portable unit

Preferred Installation Date:

Assessment Checklist (To be completed by assessor)

On-site Assessment Completed: Yes No

Structural modifications required: Yes No

Electrical upgrade required: Yes No

Permit required: Yes No

Consent, Risks, and Acknowledgments

Important: By signing below the patient (or guardian) authorizes the assessment, procurement, and installation of a heat pump device at the address listed above. The patient acknowledges and agrees to the following terms:

1. The patient has discussed the medical rationale and expected benefits with the treating clinician. The clinician's statement of medical necessity is attached to this request when required.

2. Risks associated with installation and operation include, but are not limited to: electrical shock, minor structural alterations, possible short-term disruption to utilities, and noise. Serious complications are rare. Patient accepts these risks and authorizes necessary installation activities.

3. The patient has the right to withdraw consent at any time prior to commencement of physical installation by notifying the service provider in writing. Withdrawal after commencement may not be possible without costs for work performed.

4. The patient authorizes authorized technicians to access the property for assessment, installation, and reasonable post-installation service. Reasonable efforts will be made to protect personal property.

Initial to acknowledge you have read and understand sections 1–4:

Privacy & Release of Information (HIPAA Authorization)

I authorize the release of my protected health information necessary to process this request, to contractors and technicians solely for the purpose of evaluation, installation, and billing. This release includes medical justification, limited clinical notes, and insurance billing information.

Authorization expiration date:

I authorize disclosure: Yes No

Financial Responsibility & Billing Consent

By signing, the patient authorizes billing of services to the insurance identified above. The patient acknowledges responsibility for any portion not covered by insurance, including deductibles, co-payments, and cost of modifications not deemed medically necessary by the payer.

Estimated maximum patient responsibility (if known):

I authorize billing: Bill insurance first Do not bill insurance

Acknowledgment & Certifications

By signing this form I certify that the information I have provided is accurate to the best of my knowledge. I understand that providing false or incomplete information may result in denial of services and potential financial liability for work already performed.

I certify that I have read and received a copy of any consumer notice required by the service provider regarding installation procedures, warranties, and maintenance obligations.

Acknowledgment (check to confirm): Information is true and complete

Sign Now