Healthcare Mold Agreement

HEALTHCARE MOLD AGREEMENT

Patient Information

Patient Name:

Insurance Information

Medical & Exposure History

Date symptoms or exposure first noticed:

Scope of Services and Authorization

By signing this Agreement, Patient authorizes the provision of environmental assessment services related to suspected mold exposure, including but not limited to visual inspection, air sampling, surface sampling, bulk sampling, moisture mapping, photography, and preparation of a written report with recommended remediation steps. Patient acknowledges that the provider performing the assessment is not a treating clinician unless otherwise specified.

Visual inspection    Air sampling    Surface sampling    Bulk sampling    Moisture mapping    Photography   

Estimated cost for selected services (good faith estimate): $

Patient understands that sampling may temporarily disturb mold-containing materials and may result in transient increases in airborne spores. Patient consents to the performance of the selected services and accepts the potential for inconvenience or temporary symptom increase.

Risks, Benefits, and Alternatives

The benefits of the assessment include identification of contamination sources, data to guide remediation, and documentation for medical and insurance purposes. Alternatives include foregoing environmental testing or proceeding directly to remediation without testing. Risks include disturbance of affected materials, incomplete sampling, and that sampling results may not identify all exposure sources.

Payment, Insurance & Liability

Patient agrees to be responsible for payment of services not covered by insurance. Patient authorizes billing of the listed insurer for services provided. Patient understands that issuance of recommendations does not guarantee remediation or success of remediation activities.

Patient responsible for payment    Insurance responsible    Third-party (landlord/owner) responsible

Limitation of Liability: To the fullest extent permitted by law, the provider's liability for damages arising out of or related to services performed under this Agreement shall be limited to the amount paid by or on behalf of Patient for the specific services giving rise to the claim. Provider makes no warranties, expressed or implied, regarding outcomes or remediation results.

Authorization for Release and Use of Information

Patient authorizes release of assessment results, sample reports, photographs, and written recommendations to the following parties as necessary for remediation, medical treatment coordination, or insurance claim support. Patient acknowledges that release to contractors or third parties may disclose environmental findings outside the healthcare context.

This authorization includes release of environmental data and summary medical information related to mold exposure for the purposes stated above. Patient may revoke this authorization in writing at any time except to the extent that action has already been taken in reliance on it.

HIPAA and Privacy Acknowledgment

By signing, Patient acknowledges receipt of the provider's Notice of Privacy Practices and understands that protected health information generated in connection with assessments may be used and disclosed as necessary for treatment, payment, and health care operations, and as authorized above.

Patient acknowledges the right to inspect and obtain a copy of records created pursuant to the assessment, subject to applicable law, and to request amendment of such records.

Acknowledgements & Consent

I acknowledge that I have read and understand this Healthcare Mold Agreement, that my questions have been answered, and that I consent to the services and authorizations described herein. I understand I may withdraw consent at any time by submitting written notice, subject to retention of records created prior to the revocation.

I consent to the assessment services and authorizations described above.

Certification

I certify under penalty of perjury that the information provided on this form is true and correct to the best of my knowledge. I understand that falsification of information may affect eligibility for services and may have legal consequences.

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