Healthcare Care Agreement

HEALTHCARE CARE AGREEMENT

This Healthcare Care Agreement ("Agreement") is entered into by and between Provider Name: and Patient Name: . Effective Date: .

Patient Information

Insurance Information

Medical History

Scope of Services

Provider shall deliver the services described above in a professional manner consistent with applicable standards of care. Provider is authorized to consult with other health care professionals and to obtain diagnostic and laboratory services as reasonably necessary for Patient's care.

Fees, Billing and Payment

Patient agrees to pay all charges for services rendered that are not paid by third‑party payors. Standard rate per service or hour: . Billing will be submitted to listed insurance where applicable; any remaining balance is the responsibility of the Patient or Patient's representative.

If collection or legal action is required to collect unpaid charges, Patient shall be responsible for reasonable collection and attorney fees.

I accept financial responsibility for all charges not covered by insurance, including copayments, deductibles and non‑covered services.

Consent for Treatment

Patient hereby authorizes Provider to perform the care, treatment and services described in this Agreement and any ancillary care reasonably necessary during the term of this Agreement. Patient acknowledges that no guarantee has been made as to the results of treatment.

I consent to the care, treatment and services described above and acknowledge that the risks, benefits and alternatives have been explained to me.

Risks, Benefits and Alternatives

Provider has explained the anticipated benefits, common and material risks, and reasonable alternatives to the proposed care. Patient has been afforded the opportunity to ask questions and those questions have been answered to Patient's satisfaction.

HIPAA Acknowledgment and Authorization

Patient acknowledges receipt of the Provider's Notice of Privacy Practices, and authorizes Provider to use and disclose protected health information for treatment, payment and health care operations in accordance with federal and state law.

I acknowledge receipt of the Privacy Practices and authorize use/disclosure as stated above.

I authorize the release of my medical information to the persons or entities designated by Provider for care coordination, billing, or as otherwise permitted under law.

Termination and Withdrawal

Either party may terminate this Agreement upon providing reasonable written notice to the other party. Patient may withdraw consent to treatment at any time by providing written notice; withdrawal of consent may affect Provider's ability to continue care.

Liability, Indemnification and Governing Law

Provider shall exercise reasonable care in delivering services. Provider is not liable for events beyond Provider's control. Patient agrees to indemnify and hold Provider harmless from claims arising from Patient's failure to disclose material medical information or to follow care instructions.

This Agreement shall be governed by the laws of the state in which the services are provided. Parties will first attempt to resolve disputes through good faith negotiation; unresolved disputes may be submitted to mediation or binding arbitration as agreed in writing.

Emergency Care and Transportation

In the event of a medical emergency, Provider may arrange for emergency medical services or transportation. Patient is responsible for all charges associated with emergency medical treatment and transport unless otherwise covered by insurance.

I authorize emergency transportation and accept responsibility for associated costs.

Acknowledgment and Certification

By signing below, Patient (or Patient's authorized representative) certifies that the information provided in this Agreement is true and complete to the best of their knowledge, that they have read and understand this Agreement, and that they consent to the provision of services under the terms set forth herein.

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