Healthcare Radon Mitigation Form

Healthcare Radon Mitigation Consent and Authorization

Patient Information

Date of Birth:    Gender:

Primary Phone:    Email:

Insurance Information (if billing requested)

Policy Number:    Group Number:

Medical History Relevant to Radon Exposure

Pregnancy Status: I affirm that I am currently pregnant or may be pregnant

Radon Assessment Summary

Date of Test:    Test Result (pCi/L):

Measurement Location(s):

Test Method: Short-term monitor Long-term detector Other

Recommended Mitigation Measures

The healthcare provider and mitigation specialist recommend the following measures to reduce radon exposure. These recommendations are intended to reduce measured radon concentrations but do not constitute a warranty of a specific result.

Sub-slab depressurization (active soil depressurization)

Increased mechanical ventilation (HVAC modification)

Sealing of cracks and openings in foundation

Estimated Timeline for Installation:    Estimated Cost (if provided): $

Consent, Risks, and Acknowledgements

I acknowledge that radon is a naturally occurring radioactive gas and prolonged exposure to elevated radon levels increases the risk of lung cancer. I have been informed of the recommended mitigation measures, potential benefits, and known risks associated with mitigation work, including but not limited to disruption to property, potential for increased noise, alteration of indoor airflow, and temporary loss of use of some areas of the premises during installation.

I authorize the mitigation contractor, authorized healthcare personnel, and designated agents to enter the identified premises to perform the recommended mitigation work, to access mechanical systems, and to install monitoring equipment as necessary. I understand mitigation may require drilling, routing of piping, installation of fans, and sealing of foundation openings.

I acknowledge that while mitigation substantially reduces radon concentrations in most installations, no mitigation can guarantee that radon levels will remain below any particular threshold at all times. Continued post-mitigation testing is recommended; responsibility for follow-up testing is explained below.

I acknowledge that I have read and understand the above statements regarding risks, benefits, and limitations of radon mitigation.

I grant permission for the mitigation team to access the property and to perform the recommended mitigation measures.

HIPAA Privacy and Authorization to Disclose

I authorize the healthcare provider to disclose relevant medical information related to radon exposure, including diagnoses and test results, to the mitigation contractor and authorized public health personnel as necessary for the planning and implementation of mitigation measures. Such disclosure is limited to information reasonably necessary to carry out mitigation and associated medical follow-up.

I hereby authorize the disclosure described above and understand this authorization is voluntary.

Financial and Administrative Acknowledgements

I understand that costs for mitigation may be the responsibility of the homeowner or insurer as applicable. If billing to insurance is attempted, I authorize release of necessary information for claim submission. I understand that denial of insurance coverage does not relieve me of responsibility for charges unless otherwise agreed in writing.

I agree to provide safe and timely access to the premises and to notify the mitigation team of conditions that could affect installation, including pets, structural concerns, or hazardous materials.

Certification and Acknowledgment

By signing below I certify that the information I have provided is true and accurate to the best of my knowledge. I consent to the recommended radon mitigation measures described above and authorize the release of relevant health information for the purposes stated. I understand I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on it.

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