Healthcare Ancillary Agreement

HEALTHCARE ANCILLARY AGREEMENT

This Healthcare Ancillary Agreement (the Agreement) documents the patient authorization and terms under which ancillary diagnostic, therapeutic, or support services will be provided and billed. Patient Name: . Primary Provider / Facility: .

Patient Information

Emergency Contact

Insurance Information

Medical History (Relevant)

Ancillary Services Requested

Scope and frequency:

Financial Terms; Assignment of Benefits

I authorize the ancillary provider and the facility to submit claims for services rendered to the insurance identified above and to receive payment directly from my insurer to the extent permitted by my policy. Patient understands that insurance coverage is not guaranteed and that patient is ultimately responsible for all charges not paid by insurance, including co-payments, deductibles, and non-covered services.

By checking the box below, I assign any insurance benefits related to these ancillary services to the provider and authorize release of medical information necessary to process claims.

Billing, Collections, and Payment Authorization

If insurance payment is denied or insufficient, I accept financial responsibility for balances. I authorize the facility and ancillary provider to bill my credit card or other payment method on file for outstanding balances unless otherwise agreed in writing. Failure to pay may result in collection action; patient agrees to pay reasonable collection costs, attorney fees, and interest to the extent permitted by law.

Confidentiality and HIPAA Authorization

I authorize the disclosure of my protected health information (PHI) to ancillary providers, payors, and other entities as necessary for treatment, payment, and healthcare operations related to the services described. This authorization includes release of medical records, test results, imaging, and billing records. I acknowledge receipt of the facility's Notice of Privacy Practices.

Risks, Acknowledgements, and Consent

I understand that ancillary procedures and tests may carry inherent risks, including but not limited to discomfort, infection, allergic reaction, or incidental findings that may require additional evaluation. I have had an opportunity to discuss the nature, purpose, benefits, and risks of the services with the ordering clinician and ancillary provider, and all my questions have been answered to my satisfaction.

Termination; Revocation

This authorization is effective on the date signed and remains in effect until the Authorization Expiration Date above or until revoked in writing by the patient. Revocation does not affect disclosures made in reliance on this authorization prior to revocation.

Indemnification; Limitation of Liability; Governing Law

To the extent permitted by law, patient agrees to indemnify and hold harmless the facility and ancillary providers from claims, losses, and expenses arising from the patient's failure to provide accurate information or to follow pre- or post-service instructions. Except where prohibited by law, the facility's liability for claims arising from ancillary services shall be limited to direct damages, and neither party shall be liable for consequential damages. This Agreement shall be governed by the laws of the state in which the facility is located.

Miscellaneous Provisions

Entire agreement: This document constitutes the entire agreement regarding ancillary services between patient and the facility/ancillary providers and supersedes prior oral or written statements. Severability: If any provision is held invalid, remaining provisions remain in effect.

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