Healthcare Self Storage Progress Form

HEALTHCARE SELF STORAGE PROGRESS FORM

Patient Information

Date of Birth:    Gender:    Patient ID/Record #:

Primary Phone:    Email:

Emergency / Alternate Contact

Relationship:    Phone:

Insurance Information

Policy Number:    Group #:    Subscriber Name:

Storage Authorization & Location

Patient authorizes the healthcare provider and contracted storage facility to receive, inventory, and store the described medical items and associated records for the purposes set forth below. This authorization includes handling necessary for safe storage, periodic inspection, and, when required, sanitization or disposal in accordance with applicable law and facility procedures. The patient acknowledges responsibility for ensuring items are safe for storage and for disclosing the presence of any hazardous or regulated materials.

Purpose of Storage:

Storage Location / Unit #:    Anticipated Start Date:    Anticipated End Date:

Authorization Expiration Date:

Inventory of Items to Be Stored

Complete an inventory below. Describe each item, list serial numbers where applicable, note condition, and any special handling requirements. Attach additional pages if needed.

Serial / ID #:    Condition:    Estimated Value:    From: To:

Serial / ID #:    Condition:    Estimated Value:    From: To:

Serial / ID #:    Condition:    Estimated Value:    From: To:

Serial / ID #:    Condition:    Estimated Value:    From: To:

Serial / ID #:    Condition:    Estimated Value:    From: To:

Serial / ID #:    Condition:    Estimated Value:    From: To:

Medical / Regulatory Compliance

The patient certifies that the items listed do not include prohibited hazardous materials such as untreated biohazardous waste, infectious materials, unapproved controlled substances, or radioactive matter. The patient must disclose whether items contain regulated medical devices, temperature-sensitive medications, or personal health information (PHI). Failure to disclose such materials relieves the facility of liability for proper handling and may result in immediate removal at the patient's expense.

Contains Regulated Materials or PHI: Yes No

Access, Maintenance & Emergency Procedures

Patient authorizes facility staff to access stored items for scheduled inspections, maintenance, or in the event of an emergency that threatens life, health, or public safety. The facility will provide notice when practicable; however, immediate access without notice is permitted for emergency response. Consent for non-emergency access with 24-hour notice: Yes No

Insurance, Fees & Lien

The patient acknowledges responsibility for storage fees, insurance coverage for stored items, and costs associated with removal or disposal. The facility may impose charges for handling, special maintenance, and disposal. The facility may assert a possessory lien for unpaid charges and may dispose of stored items in the manner permitted by applicable law after providing required notice.

Patient's Insurance Provider for Stored Items:

Release, Indemnification & Limitation of Liability

Except to the extent caused by the facility's gross negligence or willful misconduct, the patient releases and holds harmless the storage facility, the healthcare provider, and their agents from any loss, damage, theft, or contamination of stored items. The patient agrees to indemnify and defend facility and provider from claims arising out of the patient's failure to disclose hazardous materials or comply with applicable law. The facility's liability for loss or damage shall be limited to the lesser of the documented actual loss or the limits of any insurance maintained by the facility.

HIPAA Authorization / Privacy Acknowledgment

To the extent that storage of items involves the disclosure of protected health information (PHI), the patient authorizes the healthcare provider to disclose the minimum necessary PHI to the storage facility and its agents for purposes of inventorying, storing, retrieving, maintaining, and, if necessary, disposing of stored items. This authorization is voluntary and may be revoked in writing, except to the extent actions have already been taken relying on it.

I authorize disclosure of PHI for storage purposes: Yes No

HIPAA Authorization Expiration Date:

Medical History / Handling Instructions

Final Certification

By signing below, I certify that the information provided on this form is true, complete, and accurate to the best of my knowledge. I acknowledge that I have read and understand the terms set forth in this Healthcare Self Storage Progress Form, including the facility's rights with respect to access, maintenance, fees, and disposal. I agree to comply with all applicable rules and to notify the healthcare provider and storage facility promptly of any changes to this authorization or the contents of storage.

Sign Now