Healthcare Vehicle Lift Document

Healthcare Vehicle Lift Document

Facility Name:    Operator Name:

1. Patient Information

Date of Birth:    Gender:

2. Insurance Information

3. Medical History & Mobility

Patient Estimated Weight:    Seated Height:

Wheelchair    Power wheelchair / scooter    None / Ambulatory

4. Vehicle Lift / Equipment Details

Lift Location on Vehicle:

5. Pre-Use Inspection Checklist

Platform and surface secure, no structural damage

Controls and remote operate normally

Emergency stop functioning

Restraints, straps and tie-downs present and serviceable

Battery charged / power source available

Vehicle anchorage points secure

6. Operation & Safety Procedures

Prior to lift operation the following will be performed: patient assessment, briefing of patient on procedure, application of restraints and confirmation of weight limit. Operator will ensure clear path and vehicle secured.

Specific precautions or restrictions:

7. Consent, Acknowledgment & Release

I hereby authorize the above-named facility and its authorized personnel to operate the vehicle lift and related equipment for the purpose of transporting me. I have been informed of the nature of the lift operation, the anticipated benefits, and the potential risks, including but not limited to slips, falls, entrapment, equipment failure and exacerbation of pre-existing conditions.

By signing below I acknowledge that I have had the opportunity to ask questions and that my questions have been answered to my satisfaction. I understand that I may withdraw this consent at any time prior to the lift operation.

Release: To the extent permitted by law, I release the facility and its employees from liability for injury arising from the use of the lift except for injuries caused by gross negligence or intentional misconduct of the facility or its personnel.

I certify that I have disclosed all medical conditions, limitations and medications relevant to safe transfer and transport. I agree to inform the operator of any change in my condition prior to lift use.

I acknowledge the following (select applicable):
I acknowledge the risks of lift operation and consent to proceed.
I understand I can withdraw consent at any time prior to operation.
I accept the release terms described above.

8. HIPAA / Privacy Authorization

I acknowledge receipt of the facility's privacy practices and authorize the release of only the minimum necessary personal and medical information to individuals involved in my transport and to payors for billing purposes.

I acknowledge and authorize necessary release of information for transport and billing.

9. Authorization Period & Operator Verification

Authorization Expiration Date:

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