Healthcare Complete Care Agreement

HEALTHCARE COMPLETE CARE AGREEMENT

This Healthcare Complete Care Agreement (Agreement) is entered into by and between Provider Name: (Provider) and Patient Name: effective as of .

Patient Information

Insurance Information

Medical History

Scope of Services

Provider will render or coordinate clinical care, monitoring, and related health services consistent with the individualized care plan developed for Patient. Services may include assessment, medication management, therapy, coordination of referrals, telehealth visits, and home visits as clinically appropriate. Specific services to be provided are:

Patient grants Provider the authority to communicate with other health care professionals and to exchange clinical information as necessary to coordinate care. Patient authorizes telehealth services where clinically appropriate: I authorize telehealth visits

Financial Terms; Assignment of Benefits

Patient is responsible for all charges for services rendered by Provider. Provider will bill insurance carriers as a courtesy when authorized by Patient; however Patient remains ultimately liable for charges not covered by insurance, including co-payments, co-insurance, deductibles, and services determined to be non-covered.

Patient hereby assigns to Provider all rights to receive payment directly from Patient's insurance carrier for covered services and authorizes Provider to submit claims, to receive insurance remittances, and to act as Patient's agent for the purpose of obtaining payment. Patient authorizes release of medical information necessary for claims processing.

Consent to Treatment; Risks and Rights

Patient consents to the provision of care, diagnostic procedures, and treatments as recommended by Provider, including administration of medications, laboratory tests, imaging, and other routine interventions. Although most recommended treatments have expected benefits, all medical and behavioral interventions carry inherent risks. Patient acknowledges that Provider has explained the nature, expected benefits, material risks, and reasonable alternatives to recommended care and that Patient had an opportunity to ask questions and receive answers.

Patient understands that consent is voluntary and may be withdrawn at any time, except where withdrawal would jeopardize Patient's health or where withdrawal conflicts with clinical judgment relating to safety or legal obligations. In the event of a medical emergency, Provider may take actions necessary to preserve life and stabilize Patient until further consent can be obtained.

Privacy, HIPAA Acknowledgment & Release of Records

Patient acknowledges receipt of Provider's Notice of Privacy Practices describing how Patient's protected health information may be used and disclosed and Patient's rights under applicable privacy laws. Patient authorizes disclosure of protected health information to the following individuals or entities:

Termination; Amendment; Notices

Either party may terminate this Agreement with advance written notice to the other party as specified in Provider policies. Provider may amend terms of this Agreement to reflect changes in law, regulation, or clinical practice; amendments will be provided to Patient in writing. Notices required under this Agreement shall be effective when delivered in person or sent to the most recent address on file.

Limitation of Liability; Indemnification

Except for willful misconduct or gross negligence, Provider's liability for claims arising out of the provision of services under this Agreement is limited to direct compensatory damages and shall not include consequential, special, or punitive damages. Patient agrees to indemnify Provider for claims arising from Patient's willful misconduct or failure to disclose material medical information.

Miscellaneous Provisions

This Agreement constitutes the complete understanding between the parties regarding the subject matter and supersedes prior oral or written communications. If any provision is held invalid, the remainder remains in effect. This Agreement is governed by the laws of the state in which Provider's principal place of practice is located.

Acknowledgment and Certifications

By signing below, Patient certifies that the information provided in this Agreement is true and complete to the best of Patient's knowledge, that Patient has the authority to consent to treatment, and that Patient understands and accepts the terms, risks, and financial obligations set forth herein.

Sign Now