Healthcare Consultation Agreement

Healthcare Consultation Agreement

This Healthcare Consultation Agreement (Agreement) is entered into on Effective Date: between Provider Name: (Provider) and Patient Name: (Patient).

Patient Information

Insurance Information

Insurance type: Private Medicare Medicaid None / Self-pay

Medical History

Consultation: Purpose and Scope

Purpose of consultation:

Scope of services: Provider will perform a clinical evaluation, review relevant records, and provide professional recommendations. This Agreement does not guarantee a particular outcome. Any diagnostic testing or treatment beyond the consultation is subject to separate consent and billing.

Fees, Billing and Payment

Estimated professional fee for the consultation: $ . Patient is responsible for co-payments, deductibles, and any non-covered services. Patient agrees to pay any balance not covered by insurance.

Cancellation and missed appointment policy: Patient acknowledges cancellation fee of $ if appointment is cancelled less than 24 hours prior to scheduled time or if patient fails to appear.

I acknowledge financial responsibility for services rendered that are not paid by insurance. I authorize Provider to bill my insurance and to release information necessary for payment.

Confidentiality and HIPAA Authorization

Provider will maintain confidentiality of medical information in accordance with applicable law. By signing below, 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 as necessary.

I authorize release of records to referring providers and for billing purposes. This authorization expires on unless revoked in writing earlier. Revocation will not affect disclosures already made in reliance on this authorization.

I acknowledge receipt of the Notice of Privacy Practices and authorize use/disclosure of my protected health information as described above.

Consent to Consultation and Treatment

Patient consents to the clinical consultation and any limited examination or demonstration deemed necessary by Provider during the consultation. Patient acknowledges that the consultation may include discussion of risks, benefits, and reasonable alternatives. Patient retains the right to refuse any recommended treatment and to withdraw consent at any time.

Risks, Limitations and No Guarantee

Patient understands that medical consultation involves professional judgment that carries inherent uncertainty. Provider makes no guarantee regarding diagnosis or outcome. Patient agrees to provide accurate and complete information and to follow post-consultation instructions as advised.

Telehealth and Electronic Communications

Patient consents to communication by telephone, secure messaging, and, where applicable, telehealth platforms. Patient acknowledges risks to privacy inherent in electronic communications and agrees Provider may communicate clinical information using these means when clinically appropriate.

I consent to the use of telehealth technologies for the consultation when applicable.

Termination; Amendment; Governing Law

Either party may terminate the consultation relationship on reasonable notice. This Agreement may be amended only by written instrument signed by both parties. This Agreement is governed by the substantive laws of the state in which the Provider practices, without regard to conflict of law principles.

Representations and Acknowledgment

Patient represents that Patient is the individual named herein or the lawfully authorized representative of that individual. Patient confirms that all information provided is true and complete to the best of Patient's knowledge. Patient acknowledges receipt of a copy of this Agreement upon request.

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