Healthcare Home Modification Ramp

Healthcare Home Modification Ramp

Patient Information

Emergency Contact

Insurance / Funding

Primary Insurance Provider: Policy Number:

Funding source (check all that apply): Private insurance Medicare Medicaid Grant / Program Self-pay

Medical & Mobility History

Mobility device(s) used (check all that apply): Wheelchair Power wheelchair Walker Cane None

Assessment & Proposed Ramp

Date of Assessment: Assessor (Printed Name): Profession / Title:

Slope / Grade specification (if recommended): Ramp surface material:

Handrails required: Yes No Landing(s) required: Yes No

Cost Estimate & Financial Responsibility

Estimated total cost: $ Anticipated payer:

Patient financial responsibility (co-pay, deductible, uncovered portion): $ Patient agrees to pay amounts not covered: Yes No

Approvals & Clinical Recommendation

Clinical recommendation summary:

Recommending clinician (Printed Name): Credentials / Title:

Consent, Acknowledgment & Release

I, the undersigned, authorize installation of the residential ramp as described above. I acknowledge that the installation is based on the stated assessment and recommendations and that final design and construction may vary due to site conditions.

I understand and agree that:

1. Installation will be performed in a professional manner to meet applicable local building codes and industry standards where feasible; final compliance with local permit requirements is the responsibility of the installer and/or property owner.
2. I am responsible for ongoing maintenance, inspection, and repair of the ramp after installation to ensure continued safe use. I accept responsibility for costs of maintenance and repair unless otherwise specified in a separate agreement.
3. I accept the risk of use of the ramp and agree to notify the installer and my clinician promptly of any damage or unsafe conditions. I will not hold the recommending clinician liable for post-installation maintenance failure absent gross negligence.
4. Photos of the ramp and site may be taken for clinical documentation and program records; identifiable photographs will be used only with my express written permission.

Initial to indicate you have read and accept the above statements:

Privacy & Authorization

I acknowledge receipt of the applicable privacy notice and authorize disclosure of relevant health and billing information to contractors, payers, and grant administrators as necessary to complete installation and process payment.

Authorization expiration date:

Acknowledgment of privacy notice and authorization: I acknowledge and authorize

Program / Installer Notes

Sign Now