Client Navigator Visit

Client Navigator Visit Agreement and Report

Provider Name:     Client Name:

Recitals

WHEREAS, Provider is engaged in the business of delivering client navigation services, including assessment, coordination of referrals, and client advocacy; and

WHEREAS, Client desires to receive one or more in-person or remote visits by Provider's designated Client Navigator to assess needs, facilitate access to services, and provide documented referral and follow-up; and

WHEREAS, the parties desire to set forth the terms governing the Client Navigator visit, associated payment (if any), confidentiality of information exchanged, and the responsibilities of each party.

Scope of Work

Provider shall perform the following services during the Client Navigator visit and as reasonably required for follow-up. Provider's obligations include, but are not limited to:

Visit Details / Report

Visit Date:     Visit Location:

Follow-up Required: Yes     If yes, Follow-up Date:

Payment Terms

Client shall pay Provider for the services described under Scope of Work as follows:

Late Payment: Any amount not paid when due shall accrue interest at the lesser of 1.5% per month or the maximum rate permitted by law. Client is responsible for reasonable collection costs, including attorney fees, if Provider enforces payment rights.

Term and Termination

This Agreement commences on Start Date: and terminates on End Date: unless earlier terminated in accordance with this section.

Either party may terminate for convenience upon written notice delivered at least days prior to the effective termination date. Either party may terminate immediately for material breach that is not cured within 15 days of written notice describing the breach. Termination shall not relieve Client of obligations to pay for services already rendered.

Confidentiality

Each party shall maintain as confidential all nonpublic information disclosed by the other party in connection with the services, including personal data, health information, financial information, and records of referrals (collectively, Confidential Information). Confidential Information shall not be used or disclosed except as necessary to perform the services or as required by law. Provider will obtain Client's written authorization prior to disclosing Client's personal information to third parties, except where disclosure is necessary to secure emergency services or required by statute. Confidentiality obligations survive termination for a period of two (2) years.

Governing Law

This Agreement shall be governed by and construed in accordance with the laws of the state identified by the parties as Governing State: , without regard to conflicts of law principles. Venue for any action arising out of this Agreement shall lie in the state or federal courts located within that state.

Entire Agreement

This Agreement, together with any written exhibits or attachments signed by both parties, constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous negotiations, proposals, representations, and agreements, whether written or oral. No amendment shall be effective unless in writing and signed by authorized representatives of both parties.

Client Acknowledgment and Consent

By signing below, Client acknowledges that Provider has explained the nature and scope of the Client Navigator visit and consents to the exchange of information necessary to provide the services and referrals described herein. Client further acknowledges receipt of the Visit Report documenting assistance provided.

Client Authorization for Release of Information: I authorize Provider to share relevant information with referral agencies and service providers for the purpose of facilitating services.

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