Healthcare Patient Packet Car Seat

HEALTHCARE PATIENT PACKET — CAR SEAT ASSESSMENT & AUTHORIZATION

Patient Name:    Date of Birth:    Gender:

Patient Contact & Emergency

Insurance Information

Child & Car Seat Details

Weight (lbs):    Height (in):    Known Allergies:

Manufacture Date:    Expiration Date:

Infant / Rear-facing    Convertible    Booster    Combination

Rear Center    Rear Left    Rear Right    Front Passenger

LATCH    Vehicle Seat Belt    Both / Tether

Medical History

Assessment, Education & Findings

Date of Assessment:    Inspector Name:    Inspector ID / License #:

Harness in good condition    Buckle functions correctly    Base stable / no movement greater than 1 inch
Correct installation achieved    Recline angle appropriate for age/weight    Top tether used where required
Seat past manufacturer expiration    Seat subject to recall notice

Car seat provided    Harness clip provided    Installation tool or hardware provided

Consent, Authorization & Release

I authorize the healthcare program representative to inspect the child restraint system, demonstrate proper installation and harnessing techniques, and to provide instruction related to safe transportation of the child. I understand that instruction and inspection do not guarantee prevention of injury in the event of a crash. I accept responsibility to follow the manufacturer's instructions and the guidance provided during the session.

I acknowledge that this assessment and education is advisory and that the program and its employees, volunteers, and partners expressly disclaim liability for any injury or damages resulting from misuse, wear, alteration, improper installation post-inspection, failure to follow instructions, or subsequent events beyond the control of the inspecting party. To the fullest extent permitted by law, I release and hold harmless the providing organization from claims arising from the inspection, training, or provision of equipment.

I authorize disclosure of protected health information limited to information necessary for the administration of car seat programs, billing, or coordination of care to partner agencies and child safety programs. This authorization expires on: . I understand I may revoke this authorization in writing at any time except where actions have already been taken in reliance on this authorization.

By signing below I certify that I am the patient or authorized guardian with legal authority to consent for the child named in this form. I certify that the information I have provided on this form is accurate to the best of my knowledge.

HIPAA / Privacy Acknowledgment

I acknowledge receipt of the Notice of Privacy Practices and understand my rights regarding the use and disclosure of my protected health information. I understand that the program will use my information for treatment, payment, and healthcare operations related to the services provided herein.

Acknowledgment: I acknowledge and consent to the above privacy practices.

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