Healthcare Home Modification Installation Picklist

HEALTHCARE HOME MODIFICATION INSTALLATION PICKLIST

Patient Information

Client Name:    Date of Birth:

Female   Male   Other

Assessment and Project Location

Agency:    Assessment Date:

Funding / Insurance

Funding Source(s):  Private Pay   Medicaid   Medicare   VA   Grant   Other

Scope of Work / Client Needs

Itemized Installation Picklist

Complete each line for items to be installed. Add attachments if more lines are required.

If additional items are required beyond Item 3, attach separate continuation sheets or drawings and list attachment filenames in the Attachments section below.

Installation Requirements / Pre-Installation Checklist

Permit required   Measurements complete   Wall reinforcement required

Electrical work required   Plumbing work required   Final inspection required

Attachments / Supporting Documents

Floor plan attached   Photos attached   Measurements attached

Authorization, Risks, and Acknowledgments

I acknowledge that the proposed home modifications described in this picklist are recommended to address the Client's functional needs. I authorize the contracted installer and authorized agents to access the property to perform measurements and, if approved, to install the modifications. I understand installation may involve drilling, reinforcement, alteration of fixtures, and temporary disruption of living areas.

I understand the risks of installation may include cosmetic or structural damage, the possible need for additional corrective work, and that final fit may require on-site adjustments. I accept responsibility for providing accurate information about the residence and for removing or protecting fragile items prior to work. The organization coordinating the modification will attempt to coordinate permits when required; however, I remain responsible for permit fees and compliance when required by local jurisdiction or payer.

I authorize disclosure of relevant patient information necessary for procurement, billing, and installation to contractors, payers, and agencies involved in the modification process. This authorization expires on: .

Right to Withdraw: I understand I may withdraw consent prior to the start of installation by notifying the coordinating agency in writing. Withdrawal after commencement of work may result in charges for materials and labor already incurred.

Initial to acknowledge each statement below:

Initials — I have reviewed the scope of work and understand the proposed modifications:    Initials — I accept responsibility for non-covered costs and co-pays:    Initials — I authorize residence access as described above:

Privacy and HIPAA Acknowledgment

I acknowledge that the information collected on this picklist will be used to plan, procure, and install home modifications. I consent to the release of protected health information to parties involved in the installation and billing process as necessary to effectuate these services. I understand that my personal and health information will be handled in accordance with applicable privacy and confidentiality standards.

Acknowledgement of Privacy Statement:

Final Certification

By signing below I certify that the information provided on this picklist is true and accurate to the best of my knowledge, that I have had the opportunity to ask questions, and that I consent to the actions described herein.

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