Healthcare Mattress Document

Healthcare Mattress Provision & Consent Form

Patient Information

Patient Name:

Emergency Contact

Insurance Information

Medical History / Clinical Information

Mattress Device Details

Date Provided:    Expected Return Date:

Battery/charger included (if applicable)    Accessories included (cover, pump hoses, etc.)

Indications, Risks, Benefits and Instructions

This mattress has been provided for pressure redistribution and to reduce the risk of pressure injury. Benefits may include reduced pressure at high-risk sites and improved comfort. Risks include but are not limited to: device malfunction, improper use that may increase risk of skin injury, and allergic or irritant reaction to mattress materials.

The patient or responsible party acknowledges receipt of instructions for use, routine cleaning, alarm and pump operation (if applicable), and procedures for battery maintenance. The patient agrees to follow the care plan and to notify the provider of device issues, new wounds, or changes in mobility.

Please acknowledge the following (check all that apply):

I received verbal and written instructions for operation and maintenance of the mattress.
I understand infection control and cleaning requirements.
I understand the return and replacement policy and my responsibility for loss or damage not covered by warranty or insurer.

Billing, Ownership, Warranty and Liability

Ownership: Unless otherwise specified in a separate agreement, the mattress remains the property of the supplying organization while on loan. The patient is responsible for reasonable care and safe keeping of the equipment while in their possession. Loss, theft, or damage due to misuse may result in a charge to the patient or responsible party.

Warranty: The device is provided with the manufacturer’s standard warranty terms. Warranty performance may require return of the mattress to an authorized service provider. Routine wear and damage due to negligence are not covered by warranty.

Billing: The patient acknowledges that charges associated with rental, repair, replacement, or non-covered services may be billed to the patient or the insurer. The supplying organization will attempt to bill the insurer, but the patient remains ultimately responsible for unpaid charges.

HIPAA / Privacy Acknowledgment

I acknowledge that the supplying organization provided a notice of privacy practices describing how my protected health information may be used and disclosed in connection with the provision, billing, and servicing of this mattress. I authorize release of pertinent medical and billing information to my insurer as necessary for coverage, and I understand my rights regarding access to my medical information.

Acknowledgment: I acknowledge receipt of the notice of privacy practices.

Authorization

By signing below, I certify that the information provided is accurate to the best of my knowledge. I authorize the supplying organization to provide the mattress described above and to release or obtain information necessary for care coordination and insurance claims related to this device.

Authorization Expiration Date:

Patient Certification

I certify that I have read and understand the terms set forth in this Healthcare Mattress Provision & Consent Form. I have had the opportunity to ask questions and receive satisfactory answers. I accept responsibility for operation, routine maintenance, and safeguarding of the mattress while it is in my possession, subject to applicable warranty and institutional policies.

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