Healthcare Home Modifications Document

Healthcare Home Modifications Authorization and Agreement

Patient Name:    Date of Birth:

Address:

Contact & Referral

Insurance and Funding

Insurance / Public Payer   Private Pay   Grant / Program   Other

Clinical Assessment Summary

Assessment Date:

Proposed Modifications (Itemized)

List each proposed modification, a brief description of work to be performed, and the estimated cost. Contractor selection and final scope are subject to inspection and permit requirements.

Risks, Benefits, and Alternatives

The proposed home modifications are designed to reduce barriers and improve safety and independence. Benefits may include improved mobility, reduced fall risk, and easier access to daily activities. Risks include, but are not limited to, structural damage to the residence, temporary disruption to access while work is performed, need for future repairs, and possible incompatibility with existing utilities or building systems. The patient acknowledges that no guarantee of complete elimination of all risks is provided.

Reasonable alternatives, including assistive devices, therapy, or relocation of essential living functions within the home, have been considered and discussed as appropriate. The patient retains the right to decline any recommended modifications prior to contract execution.

Responsibilities, Permits & Compliance

The patient authorizes access to the residence by authorized representatives, clinicians, and licensed contractors for the purpose of evaluation, installation, and inspection. Contractors shall be licensed where required, and all work shall comply with applicable building codes and permit requirements. Any permits, inspections, or approvals required by local authorities are the responsibility of the contractor unless otherwise agreed in a separate contract. The patient is responsible for notifying their landlord if required and for any costs associated with landlord consent.

Authorization to Release Information

I authorize release of pertinent health and functional information necessary to plan, obtain funding for, and carry out the home modification work to contractors, funders, and agencies involved in the delivery of services. This authorization is limited to information reasonably necessary to perform the evaluation, design, and installation of the proposed modifications.

Acknowledgment and Certification

By signing below, I certify that the information provided on this form is true and accurate to the best of my knowledge and that the proposed modifications are reasonably necessary to address my documented functional limitations. I consent to the release of information described above and authorize the referral and performance of the described home modification services. I understand that final scope, cost, and scheduling will be determined by the selected contractor and may be adjusted following a site inspection.

I acknowledge that the organization coordinating this service does not assume liability for contractor performance beyond verifying licensure and insurance where applicable. I agree to indemnify and hold harmless the coordinating organization for claims arising from contractor performance, except where caused by the coordinating organization's gross negligence or willful misconduct.

Payment Authorization

I authorize billing to the indicated funding source for eligible services and agree to pay any amounts not covered by insurance or funding programs. I understand that estimates are not final and that I will be notified of material changes to scope or cost prior to commencement of work.

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