Healthcare Mold Discovery Form

HEALTHCARE MOLD DISCOVERY FORM

Patient Information

Patient Name:

Insurance Information

Medical History (relevant to exposure)

Mold Discovery Details

Discovery Date:    Time:

Discovered by: Staff Patient/Visitor Maintenance Environmental testing

Health Effects and Symptoms

Symptoms observed (check all that apply):

Cough    Wheeze    Skin irritation    Eye irritation

Nasal congestion    Headaches    Fatigue    Other:

Reported to facility management    Area isolated    Remediation initiated

Medical treatment sought    None taken

Provider Notification

Notified Primary Care Provider: Yes    No

Authorization and Privacy

I authorize release of medical information limited to records, treatment notes, diagnostic results and symptom reports related to this mold exposure incident to facility management, designated environmental assessment personnel and remediation contractors for the sole purpose of medical evaluation and environmental remediation coordination. This authorization does not permit release of unrelated medical records.

I consent to the release described above    I do not consent

I understand that I may revoke this authorization at any time by providing written notice to the facility's medical records office, except to the extent that action has already been taken in reliance on this authorization. I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by recipients and no longer protected under applicable privacy rules to the extent permitted by law.

Certifications and Notices

By signing below I certify that the information provided in this Mold Discovery Form is true and accurate to the best of my knowledge. I acknowledge that submission of this form initiates medical and environmental notification procedures and does not by itself constitute a determination of cause, liability or responsibility. I acknowledge my right to receive a copy of this completed form upon request.

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