Health Information Statement

HEALTH INFORMATION STATEMENT

Client Name:    Provider Name:

RECITALS

WHEREAS, Provider is engaged in the delivery of health-related services and requires accurate health information to provide safe and effective care; and

WHEREAS, Client desires to receive services from Provider and understands that the disclosure of accurate medical history, current medications, allergies, and related health information is essential for clinical decision-making and recordkeeping; and

WHEREAS, the parties agree to the terms set forth in this Health Information Statement to govern the collection, use, disclosure, and safeguarding of Client health information provided to Provider.

PATIENT INFORMATION

EMERGENCY CONTACT & PROVIDER

HEALTH HISTORY

CONSENT AND AUTHORIZATIONS

I authorize Provider to collect and record the health information set forth above and to use such information for the purposes of providing care, treatment planning, billing, and quality assurance. I understand that treatment may be conditioned on the provision of accurate and complete information.

Release for Emergency: I authorize disclosure of health information to emergency personnel or other treating providers when necessary to prevent harm.

Release to Family or Authorized Persons: I authorize Provider to share relevant health information with the following person(s):

SCOPE OF WORK

Describe the services, assessments, or procedures to be provided. Include frequency, location, and any limitations.

PAYMENT TERMS

Patient financial responsibility: Client agrees to pay for services not covered by insurance and to provide current insurance information. Provider will bill insurance where assignment is applicable; however Client remains ultimately responsible for payment.

TERM AND TERMINATION

This Health Information Statement is effective as of and shall remain in effect until unless earlier terminated in accordance with this section.

Termination for Convenience: Either party may terminate by providing written notice to the other at least days in advance.

Termination for Cause: Provider may immediately terminate or suspend services if Client knowingly provides false health information, poses an imminent threat to safety, or materially breaches payment or conduct obligations.

CONFIDENTIALITY

Provider shall maintain the confidentiality of Client health information in accordance with applicable privacy and health information laws. Provider will implement administrative, technical, and physical safeguards to protect information from unauthorized access, use, or disclosure.

Permitted disclosures include: treatment and care coordination, payment and billing, legal processes where required by law, and reporting obligations for public health, child or elder abuse, or other statutorily mandated disclosures. Any disclosure beyond these purposes requires Client's written authorization.

GOVERNING LAW

This Health Information Statement shall be governed by and construed in accordance with the laws of the State of without regard to its conflicts of law principles.

ENTIRE AGREEMENT

This Health Information Statement, together with any attached addenda or written amendments executed by both parties, constitutes the entire agreement between Client and Provider with respect to the subject matter herein and supersedes all prior and contemporaneous agreements and understandings, whether written or oral.

ACKNOWLEDGMENT & CERTIFICATION

By signing below, Client certifies under penalty of law that the health information provided is true and complete to the best of Client's knowledge. Client acknowledges receipt of a copy of this Health Information Statement and understands Provider's obligations and permitted disclosures described herein.

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