Healthcare At-Need Contract

HEALTHCARE AT-NEED CONTRACT

Parties and Effective Date

This Healthcare At-Need Contract (the "Contract") is entered into by and between the Service Provider named below and the Patient named below. Service Provider: . Provider address: .

Patient Name: . Effective Date: .

Patient Information

Insurance and Billing

Medical History

Scope of At-Need Services

The Provider agrees to make available, upon Patient request and subject to Provider capacity and clinical eligibility, the at-need services checked below. Provider will document each request and the response in the clinical record.

Skilled nursing visits

Personal care / assistance with activities of daily living

Medication management / administration

Hospice / palliative at-need services

Transportation to urgent appointments

Telehealth consultation

Schedule and Availability

Services provided under this Contract are on an at-need basis. Provider will make reasonable efforts to respond to requests. Expected response timeframe: . Start date for availability: .

On-call availability: 24/7 on-call as needed.

Fees, Payment, and Insurance Billing

Patient agrees to pay for services according to Provider's schedule of charges. Provider will bill the listed insurance when applicable; Patient remains responsible for co-payments, deductibles and non-covered services.

Deposit required: . If deposit required, amount:

Billing Responsibility (check all that apply):

Insurance pays primary

Patient responsible for outstanding balances

Authorization, Privacy, and HIPAA Acknowledgment

The Patient hereby authorizes Provider to use and disclose protected health information as necessary for treatment, payment, and healthcare operations in accordance with applicable privacy law. Patient acknowledges receipt of Provider's privacy practices and understands that information may be disclosed to insurers, billing agents, and other healthcare professionals as required for authorized purposes.

The Patient grants Provider permission to obtain verification of benefits and to communicate with the listed emergency contact and insurance subscriber for care coordination: I authorize.

Authorization expiration date:

Risks, Benefits and Alternatives

The Patient understands that at-need services present potential benefits, including timely clinical intervention and symptom management, and potential risks, which may include adverse reactions to interventions and limitations based on clinical judgment. Alternatives include seeking care through emergency services, scheduled clinic visits, or other community resources. Patient acknowledges that Provider has explained the nature of at-need services and alternatives.

By initialing here, Patient acknowledges understanding of risks and benefits:

Termination and Withdrawal

Either party may terminate this Contract with written notice. Patient agrees to provide advance notice where practicable. Provider may terminate immediately for reasons including but not limited to nonpayment, harmful behavior, or conditions that jeopardize safety.

Liability, Indemnification and Insurance

Provider will maintain professional liability insurance in amounts consistent with industry standards. To the fullest extent permitted by law, each party agrees to indemnify and hold harmless the other party from claims arising out of that party's negligent acts or omissions. This indemnity does not limit Patient's rights under applicable statute.

Dispute Resolution and Governing Law

The parties agree to attempt good faith negotiation of disputes. If unresolved, disputes shall be resolved by binding arbitration pursuant to the rules of the selected arbitration forum, except where injunctive relief is sought. This Contract is governed by the laws of the state where Provider is located.

Miscellaneous Provisions

Entire Agreement: This Contract constitutes the entire agreement between the parties concerning at-need services and supersedes prior agreements. Amendment: This Contract may be amended only in writing signed by both parties. Severability: If any provision is held invalid, the remainder will remain in effect.

Acknowledgment and Authorizations

By signing below, the Patient and Provider acknowledge that they have read and understood this Contract, that the Patient has had an opportunity to ask questions, and that the parties agree to the terms set forth herein.

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