Healthcare Mold Asbestos Inspection Agreement

HEALTHCARE MOLD ASBESTOS INSPECTION AGREEMENT

Parties and Property

Client Name:

Facility Contact Person:     Phone:

Patient / Occupant Information

Date of Birth:     Gender:     Phone:

Insurance and Billing (if applicable)

Policy / ID Number:     Group #:     Subscriber Name:

Relevant Medical History

Scope of Inspection Services

The inspecting firm will perform the following services as authorized by the client. The services are limited to visual assessment and the collection of environmental samples as selected below. The inspector will not perform abatement, repair, or medical diagnosis.

Visual inspection of accessible areas and documentation of observed conditions

Air sampling for mold spores (spore trap or equivalent)

Bulk material sampling for analysis (mold/asbestos suspect materials)

Surface swab sampling for microbial analysis

Post-remediation clearance testing (if requested)

Sampling, Laboratory Analysis and Reporting

Samples collected will be labeled, documented, and submitted to an accredited laboratory for analysis. The inspecting firm will provide a written report that describes observations, laboratory results, interpretation, and recommendations. The client acknowledges that laboratory turnaround, analytic techniques, and interpretation may affect results and that absolute absence of contaminants cannot be guaranteed.

Fees, Payment and Cancellation

Client agrees to pay fees for inspection, sampling, laboratory analysis, and reporting. Payment terms are due upon receipt of invoice unless otherwise agreed in writing. Client is responsible for costs of sample analysis, travel, and any expedited processing requested by the client.

Cancellation or rescheduling by the client with less than 48 hours' notice may be subject to a cancellation fee to compensate for scheduled laboratory reservations and staff time.

Access, Safety and Client Responsibilities

Client will provide safe access to all areas to be inspected and will notify the inspector of any known hazards, occupant health sensitivities, or security requirements. Client agrees to remove or relocate personnel and patients as required to permit safe performance of services. The inspecting firm will take reasonable precautions to prevent contamination but is not responsible for pre-existing contamination or for damage resulting from necessary sample collection in concealed areas.

Client grants permission for the inspector and their agents to occupy the premises for the purpose of performing the services selected above and to collect samples and take photographs as necessary.
Access Granted:

Limitations, Disclaimers and Liability

The inspection and testing are non-invasive unless expressly authorized. The inspecting firm disclaims any warranty, express or implied, including results-based warranties. Client acknowledges that sampling provides information about specific locations and times and may not represent conditions throughout the facility at other times. The inspecting firm’s liability for claims arising from the services provided under this Agreement shall be limited to direct damages not to exceed the total amount paid by the client for the inspection services; in no event shall the inspecting firm be liable for consequential, incidental, punitive, or indirect damages.

Client agrees to indemnify and hold harmless the inspecting firm from claims arising from Client’s failure to disclose relevant health, safety, or structural information.

Confidentiality and Records

Inspection reports and laboratory results are confidential and will be provided to the client and any parties specifically designated by the client. The inspecting firm will maintain copies of records in accordance with professional practice. The client authorizes the release of results to other consultants or contractors engaged by the client for the purpose of remediation, if the client so directs in writing.

HIPAA/Privacy Acknowledgment: I acknowledge that information about occupants' health provided in this form may be recorded and used only for safety planning and is protected under relevant privacy practices.

Authorization and Consent

By signing below, the undersigned authorizes the inspecting firm and its authorized agents to enter the premises described above to perform the selected inspection services, collect environmental samples, and submit such samples to appropriate laboratories. The undersigned certifies that they are the property owner, authorized agent, or legal guardian with authority to contract for the described services. The undersigned acknowledges that they have read and understand this Agreement, including the limitations, fee provisions, and liability limitations.

Miscellaneous

This Agreement constitutes the entire agreement between the parties with respect to the subject matter herein and supersedes all prior discussions and agreements. Any modifications must be in writing and signed by both parties. If any provision is found unenforceable, the remaining provisions shall remain in full force and effect. This Agreement shall be governed by applicable law as determined by the competent forum for disputes.

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