Healthcare Mobility Contract

HEALTHCARE MOBILITY CONTRACT

Parties and Identification

Provider Name:

Provider Contact Person:   Phone:

Patient / Client Information

Date of Birth:   Gender:   Phone:

Equipment and Services

Equipment Type (check all that apply):

Manual wheelchair    Power wheelchair    Mobility scooter

Walker    Cane    Patient lift / transfer device

Delivery:    Installation:    Fitting/Assessment:    Training:

Term, Fees and Payment

Term: This Agreement commences on Delivery Date: and continues until terminated in accordance with Section 9.

Billing Responsibility:   Insurance Provider:

Policy Number:   Group Number:   Subscriber Name:

Delivery, Installation, Maintenance

Provider shall deliver, install, and demonstrate the equipment and provide initial training. Provider warrants that equipment provided is in safe, working condition at time of delivery. Ongoing maintenance and repair responsibilities are described below.

Use, Safety and Training

Patient acknowledges receipt of operation and safety instructions and agrees to follow manufacturer and Provider recommendations. Patient shall not modify equipment without prior written consent of Provider. Provider will provide training on safe use; additional training sessions may be provided for a reasonable fee.

I acknowledge I have received training and operation instruction: I agree to follow safety instructions:

Insurance, Liability and Indemnification

Patient is responsible for maintaining required insurance coverage for loss, theft, and liability arising from use of equipment unless otherwise stated. Provider maintains general liability coverage as required by law. Patient agrees to indemnify and hold harmless Provider from claims arising out of misuse, alteration, or failure to follow instructions, except to the extent caused by Provider's gross negligence or willful misconduct.

Assumption of Risk and Release

Patient acknowledges that use of mobility equipment involves inherent risks. By signing this Agreement Patient knowingly and voluntarily assumes all risks associated with use, transport, and operation of the equipment, and releases Provider from claims for incidental or consequential damages except where liability is imposed by law.

HIPAA and Authorization to Use/Disclose Health Information

Patient authorizes Provider to obtain, use, and disclose health information necessary to assess mobility needs and bill insurance for equipment and services. Provider's use of such information will be limited to purposes specified in this Agreement. This authorization is voluntary and may be revoked in writing, but revocation will not affect disclosures made in reliance on this authorization prior to revocation.

Termination

Either party may terminate this Agreement upon thirty (30) days' written notice. Provider may terminate immediately for patient nonpayment, abandonment of equipment, or misuse that creates an immediate safety hazard. Upon termination, patient shall return equipment in accordance with Provider's instructions and remain responsible for charges incurred prior to termination.

Dispute Resolution and Governing Law

This Agreement is governed by the laws of the state identified in Provider Address. Parties agree to attempt resolution through good faith negotiation; if unresolved within sixty (60) days, disputes shall be resolved through binding arbitration unless otherwise prohibited by law.

Notices

All notices under this Agreement must be in writing and delivered to the addresses set forth above by hand, certified mail, or recognized delivery service. Notices are effective upon receipt.

Acknowledgments and Certification

Patient certifies that the information provided in this Agreement is true and complete to the best of Patient's knowledge, and that Patient has had the opportunity to ask questions regarding equipment, risks, and alternatives. Patient affirms receipt of the Provider's policies regarding equipment use, maintenance, and billing.

Signatures

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