Healthcare Maintenance Policy

HEALTHCARE MAINTENANCE POLICY

Provider Name:    Policy Effective Date:

1. Purpose and Scope

This Healthcare Maintenance Policy defines the responsibilities of the Provider and the Patient regarding the routine maintenance, servicing, inspection, repair, and recordkeeping for medical devices, durable medical equipment, and facility-based medical systems issued or maintained by the Provider for use by the Patient. This policy applies to maintenance performed by Provider personnel, authorized contractors, and third‑party vendors retained for equipment service. The Patient's acknowledgment of and compliance with this policy is required for continued maintenance and support.

2. Patient Information

3. Insurance and Billing

4. Medical and Equipment History

5. Equipment Issued / Maintained

CPAP/BiPAP    Home Oxygen    Infusion Pump    Mobility Aid (walker/wheelchair)

Weekly   Monthly   Quarterly   Annually   Other:

6. Provider Obligations

The Provider will perform scheduled inspections and maintenance in accordance with device manufacturer recommendations and applicable clinical standards. Maintenance work will be documented in the patient's maintenance record, and the Provider will notify the Patient of known issues that could materially affect safety or device performance. Emergency repairs will be prioritized; the Provider will make commercially reasonable efforts to provide temporary replacement equipment when required for continuity of care.

7. Patient Responsibilities

The Patient must:

• Permit access to the premises at scheduled service times or arrange an alternative approved location for maintenance;
• Keep equipment clean and stored per Provider instructions and immediately report malfunctions;
• Not attempt unauthorized repairs or modifications; unauthorized alterations void Provider maintenance obligations for the altered components;
• Promptly notify Provider of changes in address, telephone, or health status that could affect safe operation;
• Accept financial responsibility for maintenance or repair charges not covered by insurance, as set forth below.

Acknowledgment of Patient Responsibilities: I acknowledge that I have read and understand the Patient Responsibilities above.

8. Access for Service

The Patient authorizes Provider and authorized representatives to enter the premises at reasonable times for the purpose of performing maintenance, inspection, or removal of equipment. When access requires a key, gate code or other entry method, the Patient will provide access information or a means of entry. The Provider will make reasonable efforts to notify the Patient prior to non-emergency visits.

Consent to Entry: I consent to entry as described above.

9. Billing, Insurance and Out-of-Pocket Costs

Provider will bill maintenance and repair services to the designated insurance. The Patient remains responsible for copayments, deductibles, non‑covered services, and charges for repairs or replacements resulting from misuse, neglect, or unauthorized modification. Prior authorization for non‑routine repairs will be sought from the insurer when feasible; if prior authorization is denied, the Patient will be responsible for payment unless Provider agrees otherwise in writing.

10. Limitations of Liability and Indemnification

Provider's liability for maintenance and related services is limited to correction or repair of the equipment in accordance with manufacturer specifications and prevailing clinical practice. Provider is not liable for indirect, incidental, special, or consequential damages arising from equipment failure, except where such exclusion is prohibited by law. The Patient shall indemnify and hold Provider harmless from claims arising out of negligent or intentional misuse of equipment by the Patient or household members.

11. Confidentiality and Privacy

Provider will maintain maintenance records and any personal health information generated in the performance of maintenance in accordance with applicable privacy laws and Provider policy. Maintenance records necessary for clinical care or billing may be disclosed to other health care providers, insurers, or authorized representatives as required for treatment or payment. By signing below, the Patient acknowledges receipt of Provider's privacy practices and permits necessary disclosures for maintenance and billing purposes.

Acknowledgment of Privacy Practices: I acknowledge receipt of the Provider's privacy practices and authorize disclosures as described above.

12. Authorization and Expiration

The Patient authorizes Provider to perform maintenance and necessary repairs on the equipment specified in this Policy. This authorization remains in effect until revoked in writing by the Patient or until the expiration date below, whichever occurs first. Revocation will not affect actions taken by Provider prior to receipt of written revocation.

13. Termination

Provider may terminate maintenance services upon material breach of this Policy by the Patient, nonpayment of undisputed fees, or when continuation of service is clinically contraindicated. Upon termination, equipment may be retrieved by Provider according to applicable laws and contractual terms.

14. Right to Withdraw

The Patient may withdraw consent for continued maintenance at any time by providing written notice to Provider. Withdrawal of consent may result in discontinuation of maintenance services and potential termination of equipment provision; the Patient remains responsible for fees incurred prior to withdrawal.

15. Dispute Resolution

Any dispute arising under this Policy shall first be referred to Provider's patient relations department for informal resolution. If unresolved, disputes may be subject to mediation or other alternative dispute resolution procedures agreed by the parties. Nothing in this section limits either party's right to seek urgent equitable relief where necessary to prevent harm.

16. Certification and Acceptance

By signing below, the Patient certifies that all information provided in this document is true and complete to the best of their knowledge; that they have had the opportunity to ask questions about maintenance procedures, risks, and financial responsibilities; and that they accept the terms of this Healthcare Maintenance Policy.

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