Healthcare Property Document

HEALTHCARE PROPERTY DOCUMENT

Patient Name:   Date of Birth:   Gender:

Patient Contact and Emergency Information

Insurance Information

Relevant Medical Information

The following medical information is provided because certain personal property (for example implanted or external medical devices) may affect clinical care or property handling. Complete all that apply.

Property Inventory (Record of Items)

List all items brought into the facility. For each item provide description, serial number (if applicable), estimated value, and the location/storage disposition assigned by facility staff.

If additional items exist, attach an inventory continuation sheet to this document and list the attached sheet reference below.

Facility Handling, Storage, and Liability

The facility shall make reasonable efforts to safeguard patient property. The facility's liability for loss or damage to property is limited as set forth below. The patient acknowledges that certain items (cash, jewelry, high-value electronics) should not be retained in the patient room unless specifically secured. The facility is not liable for loss or damage to property unless caused by the facility's gross negligence or willful misconduct.

The patient authorizes the facility to: inventory and take temporary custody of listed items; store items in a locked safe or other secure location; release items only to the patient or to an authorized person designated in writing by the patient. The facility may dispose of or transfer abandoned property in accordance with applicable internal procedures if property remains unclaimed after 30 days following discharge.

The patient affirms that the estimated values listed are their good-faith estimates. The patient understands that any insurance recovery for loss or damage remains the responsibility of the patient and that the facility may cooperate with claimant's insurance carrier and law enforcement in the event of loss, theft, or damage.

Patient Directives and Authorizations

I authorize the facility to release my property only to the persons named below or to the patient. I may revoke this authorization in writing at any time, except to the extent that the facility has already acted in reliance on this authorization. I understand that this authorization will remain in effect until the expiration date listed below or until revoked in writing, whichever occurs first.

HIPAA / Privacy Acknowledgment

I acknowledge that the inventory and handling of my property will require the facility to record identifying information. I understand that such records are part of my medical and administrative record and will be protected in accordance with applicable privacy rules. By signing below I acknowledge receipt of and have been provided an opportunity to review the facility's privacy practices as they relate to property inventory.

Certification and Signatures

By signing below I certify that the information I have provided on this form is true and accurate to the best of my knowledge. I acknowledge that I have read and understand the facility's policies regarding personal property, storage, release, and liability as stated herein and that I have had the opportunity to ask questions and receive answers.

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