Healthcare Mold Air Assessment

HEALTHCARE MOLD AIR ASSESSMENT

Purpose: This Mold Air Assessment documents patient exposure history, symptomology, environmental sampling details, laboratory receipt, and clinician recommendations. Completion of this form authorizes air quality sampling in connection with clinical evaluation and creates a record to inform diagnosis and management. Results are interpretive and subject to laboratory limitations described below.

Patient Information

Date of Birth:    Gender: Male   Female   Other   Prefer not to say

Insurance Information

Exposure & Environmental History

Building Type: Home   Workplace   School   Other   If Other, describe:

Visible mold observed: Yes   No    History of water intrusion/flooding: Yes   No

Medical History & Symptoms

Assessment & Sampling Details

Date of Assessment:    Assessor Name:

Spore trap air sampling   Viable culture sampling   Bulk material sampling   Surface swab   Other

Laboratory / Chain of Custody

Sample Received Date by Lab:    Report Issued Date:

Authorizations, Notices, and Certifications

Authorization to Conduct Environmental Sampling: I authorize the named assessor and laboratory to collect airborne and environmental samples at the stated location for the purpose of clinical evaluation and environmental assessment. I understand that sampling results are subject to laboratory methodology, sample quality, and temporal variability, and do not alone establish a clinical diagnosis.

Release and Limitation of Liability: To the extent permitted by law, I acknowledge that the assessor, clinic, and laboratory are not guarantors of remediation outcomes. I release the assessor and clinic from liability for environmental conditions beyond reasonable control and acknowledge that remediation decisions rest with property owners and responsible parties.

HIPAA / Privacy Acknowledgment: I acknowledge that health and sampling information collected as part of this assessment will be maintained in accordance with applicable patient privacy laws. I consent to the release of sample results and relevant clinical findings to the patient and designated healthcare providers for continued care.

Certification: I certify under penalty of perjury that the information provided on this form is true and correct to the best of my knowledge and that I have the authority to authorize access to the stated property for sampling when applicable.

I acknowledge receipt of the clinic's privacy practices and understand my rights with respect to the use and disclosure of my health information.

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