Healthcare IV Pole Document

HEALTHCARE IV POLE DEVICE ACKNOWLEDGMENT AND RECEIPT

Patient Information

Patient Name:

Date of Birth:    Gender:

Insurance Information

Medical History (Relevant to Device Use)

Device Details and Inventory

Device Type:    Model:

Serial Number:    Inventory Tag:

Date Issued:

New    Used    Refurbished

Pole assembly    Base with casters    Infusion pump bracket    Hook(s) / hanger(s)    Other (describe below)

Training, Instructions, and Use

I acknowledge receipt of device operation and safety instructions and have been trained in safe use: In-person demonstration Written instructions provided Video or digital demonstration

Safety Notices, Risks and Use Limitations

The IV pole is a medical accessory intended to support intravenous fluids and related medical devices. Use of the device involves inherent risks including tipping, entanglement, pinch injuries, contamination if not cleaned, and failure of attached devices if not secured. The patient or caregiver must not modify the device, overload with excessive weight, or use for unsupported purposes. Use near stairs, in tub/shower areas, or where cords may present a trip hazard is prohibited unless specifically instructed.

The patient agrees to maintain a secure, level location for the device, to follow cleaning and maintenance instructions, and to ensure that lines and tubing are routed so they do not create a fall or entanglement hazard. Report any instability, broken casters, loose fasteners, missing components, or other malfunction to the issuing provider within 24 hours.

Responsibilities, Return, and Financial Liability

The device remains the property of the issuing healthcare provider. The patient accepts temporary custody and is responsible for reasonable care and safe use while in their possession. The patient will return the device and all issued components upon request, upon discharge from services, or no later than the agreed return date. The patient agrees to return the device in substantially the same condition as issued, ordinary wear and tear excepted.

The patient is liable for replacement or repair costs caused by loss, theft, negligent damage, or unauthorized modification. If replacement cost assessment is necessary, the patient authorizes the provider to charge the patient or the patient’s responsible party. Replacement cost (estimate) if lost or destroyed: $

HIPAA / Privacy Acknowledgment

I acknowledge that information collected on this form is part of my medical record and may be used and disclosed for the purposes of treatment, device provisioning, billing, and care coordination. I acknowledge receipt of the provider's privacy practices and consent to communications necessary for service, repair, or recovery of the device.

I acknowledge receipt of privacy practices and consent to uses and disclosures as described above.

Authorization for Device Recovery / Release

By signing below I authorize the issuing provider or its agents to enter my residence at a reasonable time to retrieve the device if it is not returned within the agreed timeframe, or to take other actions reasonably necessary to recover the device following notification. I understand that recovery may only occur after reasonable notice unless an immediate safety concern is identified.

Authorization Expiration Date:

Acknowledgment and Certification

By signing below I certify that the information provided on this form is true and complete to the best of my knowledge. I acknowledge that I have received the IV pole and the components indicated above, have received instruction and demonstrated understanding of safe operation and cleaning, and accept responsibility for the device while it is in my possession. I hereby release the issuing provider from liability for equipment failure or harm resulting from failure to follow instructions, misuse, or unauthorized modifications.

I understand that this acknowledgement constitutes a contractual agreement regarding custody, care, return, and liability for the device described herein.

Staff Acknowledgment (For Issuing Personnel)

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