Healthcare Mobility Program

HEALTHCARE MOBILITY PROGRAM ENROLLMENT AND CONSENT AGREEMENT

Program Overview

This Healthcare Mobility Program provides mobility assessments, equipment issuance, training, maintenance and related services to improve patient mobility, safety and independence. Participation is voluntary and subject to medical eligibility, program policies, and acceptance of the terms set forth in this Enrollment and Consent Agreement.

Patient Information

Date of Birth:

Male Female Non-binary Other Prefer not to say

Insurance and Payer Information

Medical and Mobility History

Mobility Needs and Environment

Primary mobility device requested or recommended:

Cane Walker Manual wheelchair Power wheelchair Scooter

Consent for Assessment and Services

I authorize licensed clinicians and authorized program staff to perform mobility assessments, home safety evaluations, device fitting, training and follow-up services. I understand that assessments will include physical examination of mobility function, measurement for equipment, and observation of transfers and ambulation as appropriate.

I understand the potential benefits include improved mobility and safety. I acknowledge that risks may include skin irritation, falls, discomfort during assessment or training, and equipment malfunction. Program staff have explained the nature and purpose of recommended services and alternatives, and I had the opportunity to ask questions.

I consent to the assessment and provision of mobility services described above and accept that I may withdraw consent at any time by notifying program staff in writing.

Equipment Issuance, Use and Maintenance

Equipment issued through this program may be provided as loaned equipment or provided outright according to program policy and payer authorization. All issued equipment remains subject to program requirements concerning maintenance, safe use, and return when requested.

I agree to follow manufacturer and program instructions for safe operation, to report damage or malfunction promptly, and to present equipment for inspection or repair upon request. I accept financial responsibility for loss, theft, or damage resulting from misuse, negligence, or failure to follow instructions, except as otherwise required by law or payer agreement.

I acknowledge and accept the equipment issuance, use and maintenance terms stated above.

Privacy and HIPAA Authorization

By signing below I acknowledge receipt of the program's privacy practices and authorize the release of my protected health information to the extent necessary for assessment, equipment ordering, billing and coordination of care with other providers and payers. This authorization includes, but is not limited to, records related to mobility assessments, device specifications, and billing information.

I understand I may revoke this authorization at any time by submitting written notice, except to the extent that actions have already been taken in reliance on this authorization.

Authorization Expiration:

I acknowledge the privacy notice and authorize disclosure as described above.

Release of Information (Optional)

I authorize the program to share pertinent mobility assessment and equipment information with the following individual(s) or agency(ies) for care coordination:

Financial Responsibility and Billing

I authorize billing of program charges to the listed payer(s) and accept responsibility for co-payments, deductibles, non-covered services, or charges denied by my insurer. I understand the program will attempt to obtain required authorizations prior to equipment issuance but that ultimate payment liability may rest with me if authorization is denied or rescinded.

I accept financial responsibility as described above.

Emergency Medical Treatment Consent

In the event of an emergency arising during assessment or program activities, I authorize program staff to obtain emergency medical treatment as reasonably necessary. I understand that I am responsible for related medical costs not covered by insurance.

I consent to emergency medical treatment as described above.

Program Duration and Termination

Participation is effective upon acceptance into the program and remains in effect until the equipment is returned, the program determines the participant no longer requires services, the participant withdraws consent, or the participant is discharged for cause. The program may terminate services for noncompliance with program policies or safety concerns.

Attestation

By signing below I attest that the information provided on this form is true and accurate to the best of my knowledge. I understand that false or incomplete information may affect program eligibility and may result in denial of services.

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