Healthcare Mold Services Agreement

HEALTHCARE MOLD SERVICES AGREEMENT

This Healthcare Mold Services Agreement ("Agreement") is made effective as of by and between the Client/Facility: and the Service Provider: . Services will be performed at:

1. Patient / Occupant Information

Date of Birth:    Gender:

2. Insurance & Billing

3. Medical History

4. Scope of Services

The Service Provider shall perform the following services at the Service Location: initial inspection, testing, containment, remediation, and clearance verification as required to address mold or suspected mold growth. Specific services selected (check all that apply):

5. Scheduling, Access, and Patient Relocation

Anticipated Start Date: . Estimated Duration: . Client or facility shall provide access to the Service Location and any areas reasonably required to perform the services.

Patient relocation required during active remediation: . If relocation is required, Patient Relocation Plan summary:

6. Infection Control & Containment Protocols

The Service Provider shall implement industry-standard containment, personal protective equipment (PPE) use, HEPA filtration, and decontamination procedures appropriate for healthcare environments. Provider shall coordinate with facility infection control staff and comply with the facility's isolation and sanitation protocols. Any exceptions from standard protocols must be documented and approved in writing by the Client or facility infection control representative.

7. Risks, Benefits, and Right to Withdraw

The Client acknowledges that remediation activities may require temporary disturbance of building materials and that minor airborne particulate release may occur despite containment. Benefits include remediation of mold growth and reduction in airborne spores. The Client or Patient may withdraw consent for non-emergency services at any time prior to commencement of activities by providing written notice to the Service Provider; withdrawal does not relieve the Client of payment for services already performed or reasonable cancellation fees described in Section 11.

8. Liability, Indemnification, and Insurance

The Service Provider shall maintain commercial general liability and pollution remediation insurance appropriate to the scope of services. Provider's overall liability for direct damages shall be limited to the amount paid by the Client under this Agreement up to . Neither party shall be liable for incidental, consequential, punitive, or special damages. Client shall indemnify and hold Provider harmless from claims arising from Client's failure to disclose relevant medical conditions, locations of medical equipment, or hazardous materials.

9. Fees, Payments, and Deposits

10. Cancellation & Termination

Either party may terminate this Agreement for material breach upon providing written notice and a reasonable opportunity to cure. Cancellation by Client within days of scheduled work may incur a cancellation fee equal to the Deposit and any reasonable costs incurred by Provider.

11. Confidentiality & HIPAA

Provider shall maintain the confidentiality of all patient and facility information encountered in the performance of services. Provider shall not access, use, or disclose protected health information (PHI) except as necessary to perform the services and only in accordance with the Client's written authorization below. Provider agrees to implement safeguards to prevent unauthorized disclosure.

By signing below, Client authorizes the Service Provider to access and use only the minimum PHI necessary to perform the services described in this Agreement. This authorization expires on: .

The Client acknowledges the right to revoke this authorization in writing, except to the extent that the Service Provider has already acted in reliance on this authorization.

12. Compliance with Laws and Facility Policies

Provider shall comply with applicable laws, rules, and regulations governing healthcare facilities and environmental remediation. Provider shall comply with facility-specific policies supplied in writing prior to commencement of work, including infection control and patient privacy protocols.

13. Miscellaneous

This Agreement constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior negotiations, representations, and agreements. Amendments to this Agreement must be in writing and signed by both parties. If any provision is held invalid, the remaining provisions shall remain in full force and effect.

Acknowledgment

By signing below, the Client/Facility Representative certifies that the information provided in this Agreement is true and complete to the best of their knowledge, that they have the authority to request services at the Service Location, and that they have reviewed and accept the terms set forth herein.

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