Healthcare Care Center Agreement

Healthcare Care Center Agreement

This Healthcare Care Center Agreement (the Agreement) is entered into between the Care Center and the patient identified below for the provision of medical, nursing, therapeutic and related supportive services. The parties agree as follows:

Identification and Admission

Care Center Name:

Patient Name:    Date of Birth:

Insurance and Billing

The patient authorizes the care center to bill insurance and to obtain payment directly from insurance carriers to the extent permitted. The patient remains responsible for co-payments, deductibles and any non-covered services.

Medical History

Consent for Treatment

Description of Services: The care center will provide those services set forth in the individualized plan of care developed with the patient, which may include medical evaluation, medication administration, nursing care, therapy, rehabilitation, and supportive services. Specific procedures to be performed are described below.

Risks and Benefits: The patient acknowledges that the care center has provided an explanation of the anticipated benefits, significant risks and possible complications associated with the proposed treatment or services, as well as reasonable alternatives. The patient understands that no guarantee has been made regarding the outcome.

Right to Withdraw: The patient understands the right to refuse or withdraw consent to treatment at any time, except to the extent otherwise provided by law or adjudication, and that withdrawal may affect continuity of care.

  I consent to the provision of the described services and agree that this consent authorizes routine medical care related to the services above.

Privacy, Records and Release

HIPAA Authorization and Acknowledgment: The patient acknowledges receipt of the care center's privacy practices and authorizes the use and disclosure of protected health information for treatment, payment and healthcare operations as necessary. The patient authorizes the care center to obtain medical records from prior providers and to disclose records to insurers, other providers and as required by law.

Release of Information: The patient authorizes release of medical information to the following person(s) for purposes of care coordination:

  I acknowledge that I have received the privacy notice and authorize the described uses and disclosures of my protected health information as set forth above.

Financial Responsibility and Assignment

The patient agrees to pay all charges for services not covered by insurance, including co-payments, coinsurance and deductibles. The patient assigns benefits to the care center to the extent permitted and agrees to cooperate in obtaining insurance payments.

  I assign insurance benefits to the care center and authorize direct payment to the care center for services rendered.

Authorization Period and Termination

This authorization is effective as of the date below and shall remain in effect until revoked in writing by the patient, or until: Expiration Date:

Revocation of this authorization does not affect disclosures made prior to revocation in reliance upon the authorization.

General Terms

Governing Law and Dispute Resolution: This Agreement shall be governed by the laws applicable where the care center is located. Any dispute arising under this Agreement shall be addressed first through good faith negotiation; if unresolved, the parties may pursue dispute resolution according to applicable law.

Liability: The care center shall exercise reasonable care in providing services. The care center is not responsible for acts beyond its control or for unauthorized actions by third parties.

Entire Agreement: This Agreement constitutes the entire agreement between the parties with respect to the subject matter and supersedes prior understandings.

Acknowledgment and Signature

By signing below, the patient or authorized representative certifies that they have the legal authority to sign, have read and understand this Agreement, and consent to the terms herein.

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