Healthcare Assessment Proposal

HEALTHCARE ASSESSMENT PROPOSAL

Provider Name:    Provider Contact:

Client Name:    Date of Birth:

Patient Information

Male    Female    Other / Prefer to self-describe:

Insurance Information

Medical History (Relevant)

Assessment Proposal — Scope and Methodology

Purpose:

Cognitive assessment (neuropsychology)
Functional assessment (ADLs/IADLs)
Behavioral assessment
Mobility / physical therapy screening
Psychiatric evaluation / risk assessment
Social support and resource assessment

Proposed Assessment Start Date:    Estimated Completion Date:

Fees, Billing and Payment Terms

Service Description:   Amount: $

Service Description:   Amount: $

Estimated Total Fee: $

Responsibilities and Access

Provider Responsibilities: The Provider will perform assessments in accordance with accepted professional standards, document findings in a written report, and provide recommendations. Provider will secure written authorization for any release of protected health information. Any subcontracted professionals will be disclosed to the Client prior to engagement.

Client Responsibilities: The Client agrees to provide accurate medical and psychosocial history, ensure access to the patient and relevant records, and to inform Provider of any third-party payer requirements or scheduling constraints.

Confidentiality; HIPAA Acknowledgment

All assessment records and communications created as part of the services are protected health information under applicable privacy laws. Provider will maintain confidentiality consistent with applicable law. Provider may disclose information only as authorized in writing or as otherwise permitted by law (e.g., imminent risk of harm).

By checking the box below, Client acknowledges receipt of the Provider's privacy practices and consents to the collection and use of Protected Health Information for the purposes of conducting the assessment, preparing reports, and coordinating care or payment.

I acknowledge receipt of privacy practices and authorize the use of my PHI as described above.

Authorization Expiration Date:

Limitations; Cancellation

Limitations: The assessment is limited to the scope set forth in this Proposal. Recommendations are based on information available at the time of assessment and do not constitute guarantees of future outcomes. Provider disclaims liability for decisions made by third parties on the basis of the assessment.

Cancellation / Rescheduling: Client agrees to provide at least days' notice for cancellations. Late cancellations or missed appointments may incur a cancellation fee of $ .

Acceptance and Authorization to Proceed

If the Client accepts this Proposal, please sign below. Signature constitutes agreement to the scope, fees, and terms set forth herein and authorizes the Provider to schedule and perform the assessment.

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