Healthcare Vehicle Lift Form

HEALTHCARE VEHICLE LIFT FORM

Facility Name:    Unit/Vehicle ID:

Patient Information

Date of Birth:    Gender: Male Female Other

Phone:    Emergency Contact:    Emergency Phone:

Insurance / Billing Information

Policy Number:    Group #:    Subscriber Name:

Transport & Lift Details

Transport Date:    Pickup Location:

Destination:

Boarding assistance onto vehicle Securing mobility device in vehicle Patient transfer (with attendant)

Mobility Device Information

Device Type: Manual wheelchair Power wheelchair Mobility scooter Stretcher

Approximate Weight of Patient:    Mobility Device Weight (if known):

Seat Width:    Seat Depth:    Footrests Removable:

Safety Checklist (to be completed by transport staff)

Wheelchair brakes locked and secured

Lift weight capacity confirmed adequate

Power chair battery disconnected/secured (if applicable)

Patient restraints/seat belt applied as required

Lift and ramp operationally tested prior to use

Medical / Mobility Status

Current Medications (relevant to transport):

Allergies:

Consent, Release, and Authorization

I, the undersigned patient or legal representative, authorize the use of the vehicle lift and related transfer assistance for the transport described above. I acknowledge that I have been advised of the nature of lift-assisted transfers, including the risks of minor or major injury, equipment malfunction, tipping, falling, skin shear, or exacerbation of medical conditions. I understand that while reasonable care will be taken, no transport is without risk.

I certify that the information provided regarding my weight, mobility device, and medical condition is accurate to the best of my knowledge. I further acknowledge that certain mobility devices, accessories, or patient behavior may affect the safe operation of the lift. I agree to notify transport personnel of any known risk factors or device defects before boarding.

By signing below I release and hold harmless the facility, its officers, employees, agents, and contracted transport providers from liability for injury or damage arising from the use of the vehicle lift, except to the extent caused by gross negligence or willful misconduct. I further agree to indemnify the facility and transport provider for claims resulting from inaccurate information I provided regarding weight or device condition.

I understand I may withdraw this consent at any time prior to the lift operation; however, withdrawal may result in the transport being delayed or declined if safe transfer cannot be achieved without lift assistance.

This authorization is valid through:

HIPAA / Privacy Acknowledgment

I acknowledge that information necessary for the safe completion of transport (medical condition, mobility needs, and contact information) may be shared among facility staff and contracted transport personnel for the purpose of providing transportation services. I authorize this limited disclosure for the transport event identified above.

I acknowledge and authorize the limited use and disclosure of my protected health information as stated above.

Driver / Technician Verification (for staff use)

Technician/Driver Name:    Badge/ID #:

Vehicle Unit:    Time On Scene:    Time Departed:

Technician Observations / Actions Taken:

Patient / Representative Certification

I certify under penalty of perjury that the information I have provided on this form is true and accurate. I have read and understand the risks and responsibilities described above and consent to the use of the vehicle lift and related assistive measures for the transport requested.

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