Healthcare Repair Request Form

HEALTHCARE REPAIR REQUEST FORM

Use this form to request inspection, maintenance, or repair of medical equipment owned, issued, or used by the patient within the healthcare facility or in the patient's residence when provided by the facility. Completion of this form authorizes authorized personnel and third‑party vendors to access the equipment and limited patient information necessary to diagnose and complete repairs.

Patient Information

Date of Birth:    Gender:

Equipment Information

Manufacturer:    Model:    Serial #:

Under warranty: Yes    No    Insurance coverage for repairs: Yes No

Repair Details

Urgency: Routine    Urgent    Emergency

Are there batteries, data, or consumables that may be affected by repair? Yes    No

Access, Scheduling & Vendor Authorization

I authorize facility staff and contracted repair vendors to access the equipment at the location specified above and, if necessary, to enter the premises for the purpose of inspection and repair. I understand this authorization is limited to access required for repair activities and does not constitute general authorization for unrelated entry.

Do you permit repair technicians to remove the device from the premises if required for repair? Yes    No

Insurance and Billing

Policy / ID #:    Group #:

Subscriber Name:

Billing Responsibility: Patient/Guarantor    Facility    Insurance    Other

Privacy, Authorization & Liability

Authorization to Disclose and Use Health Information for Repair: I authorize the facility to disclose to authorized repair vendors and their employees only the minimum necessary protected health information (including patient name, contact information, equipment type and clinical information relevant to repair) required to complete diagnosis and repair. I understand that such disclosures are limited to repair and maintenance activities and that vendors will be required to protect patient information in accordance with applicable privacy obligations.

Release and Liability Acknowledgment: I acknowledge that the facility and contracted vendors will exercise reasonable care in performing repairs but are not responsible for pre‑existing damage, cosmetic damage, depletion of consumables (for example oxygen tubing, batteries), or loss of data stored on medical devices. I accept financial responsibility for repairs not covered by warranty or insurance and understand I will be notified prior to any non‑emergency repair that will incur patient charges.

Right to Withdraw: I understand I may withdraw this repair authorization at any time prior to commencement of the repair activity by notifying the facility in writing or by phone. Withdrawal will not affect any actions already taken in reliance on this authorization.

By signing below, I certify that the information provided on this form is true and complete to the best of my knowledge, I authorize the actions described above, and I have read and understand the statements in the Privacy, Authorization & Liability section.

Office Use Only

Assigned To:    Date Received:

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