Healthcare Nutrition Machines

Healthcare Nutrition Machines — Patient Equipment Agreement & Consent

Patient Information

Date of Birth:    Gender:

Relationship:    Phone:

Insurance & Billing

I understand that billing for the nutrition machine and associated supplies may be submitted to my insurance. I remain financially responsible for charges denied by my insurer, for deductible and copayment amounts, and for loss or damage to equipment not covered by insurance.
I acknowledge financial responsibility as stated above.

Clinical & Medical History

Equipment Details

Device provided: Enteral Feeding Pump Parenteral Infusion Pump Gravity/Bag Feeder Other

Training, Use & Safety

The patient (or responsible caregiver) will receive device-specific training covering operation, troubleshooting, alarm response, cleaning, and infection control. Training includes demonstration and return demonstration. Patient agrees to follow manufacturer instructions and training provided by the supplier.

Training provided: Yes No    Date of Training:

Patient / Caregiver responsibilities include: following prescribed feeding regimen, ensuring electrical safety, maintaining clean technique, responding promptly to alarms, and contacting the supplier or clinician for device malfunctions. Patient agrees not to alter or repair the device except by authorized service personnel.

Risks, Benefits & Alternatives

Risks associated with use of nutrition machines may include mechanical failure, pump occlusion, tubing disconnection, infection, aspiration, skin irritation from adhesives, and interruptions in nutrition delivery. Benefits include reliable, consistent nutrient delivery as prescribed and the potential avoidance of hospital-based care. Alternatives include manual gravity feeding, oral supplementation if feasible, or facility-based nutrition support. Patient has had the opportunity to ask questions and has discussed alternatives with the ordering clinician.

Maintenance, Servicing & Release of Information

Authorized service personnel may need access to device settings and limited medical information to perform maintenance. Patient hereby authorizes the supplier to disclose and receive only the information necessary for service and billing purposes. Patient also authorizes entry to the home for scheduled maintenance or urgent servicing as reasonable.

I authorize release of necessary information to service technicians and suppliers. I do not authorize release (service may be limited).

Infection Control & Home Environment

Patient agrees to follow cleaning and infection control procedures provided by the supplier and clinician. The patient will maintain an environment free of obvious contamination and will store supplies in a clean, dry area. Do not immerse electrical components in liquid.

Loss, Damage & Return Policy

Equipment provided on loan or rental remains the property of the supplier. Patient agrees to return the device and all supplied accessories within the time frame specified by the supplier. Patient may be charged for replacement or repair costs due to loss, theft, neglect, or misuse.

Privacy & Authorization

I acknowledge receipt of the supplier's privacy practices and authorize the use and disclosure of my protected health information, as necessary for provision of equipment, billing, servicing, and coordination of care. I authorize my clinician to release clinical information relevant to the prescription, training, and servicing of the device.

Authorization expires on:    (If left blank, authorization will remain in effect until device return or termination by patient.)

Acknowledgment & Certification

By signing below, I certify that I have read and understand this agreement, that the device and training were explained to me, and that I have had an opportunity to ask questions. I accept responsibility for following instructions, for notifying my clinician and the supplier of problems, and for safeguarding the equipment.

I understand that the supplier provides the equipment pursuant to the ordering clinician's prescription. Except for any express warranty provided in writing by the supplier, the supplier makes no additional warranties and is not liable for clinical outcomes resulting from the therapy. To the extent permitted by law, I agree to indemnify and hold harmless the supplier for claims arising from misuse of the device.

I received a copy of this agreement and device instructions.

Ordering Clinician

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