Healthcare Consultation Contract

HEALTHCARE CONSULTATION CONTRACT

Document Analysis

This Healthcare Consultation Contract is a bilateral agreement between a healthcare Consultant (provider) and a Patient (client). A complete, enforceable version includes: identification of parties; patient demographic, insurance and medical history; a clear description of consultation services; fees and payment terms; term and termination provisions; confidentiality and HIPAA-related language governing protected health information; allocation of responsibilities; limitations of liability; dispute resolution and governing law; authorization to access medical records; and signature lines for both parties. The contract must include a HIPAA acknowledgment and an authorization expiration date for releases.

Parties and Identification

Provider Name:

Provider Address:

Patient Name:    Date of Birth:

Insurance Information

Medical History Summary

Consultation Services and Scope

Provider will furnish professional consultation services to Patient consisting of assessment, diagnosis review, recommendations, and written consultation report as described herein. Specific consultation topic(s):

Location / Mode of Consultation: . Expected duration per session:

Fees, Billing and Payment

Consultation Fee: $ per session. Additional services or reports billed at $ per hour.

Payment is due within days of invoice. Patient agrees to be responsible for charges not covered by insurance.

Credit / Debit Card    Check    Insurance Assignment

Term, Termination and Cancellation

This Agreement commences on the Effective Date below and remains in effect until completion of the services or earlier termination. Either party may terminate for material breach upon written notice. Cancellation by Patient within hours of an appointment may result in a cancellation fee.

Confidentiality and HIPAA

Provider shall maintain the confidentiality of Patient health information in accordance with applicable law, including the Privacy Rule governing protected health information. Provider may disclose information as required by law or with Patient's written authorization. Patient acknowledges receipt of the Provider's Notice of Privacy Practices and consents to the use and disclosure of protected health information for treatment, payment and healthcare operations.

Patient hereby authorizes Provider to obtain medical records reasonably necessary to perform the consultation. Authorization expires on: .

Patient Responsibilities

Provider Responsibilities and Limitations

Provider will exercise professional skill and judgment consistent with applicable standards. Provider does not guarantee specific outcomes. Clinical recommendations are advisory and do not replace primary care or emergency care when needed.

Liability, Indemnification and Insurance

To the maximum extent permitted by law, Provider's liability arising from the services performed under this Agreement is limited to direct damages not to exceed the total fees paid by Patient to Provider under this Agreement. Patient agrees to indemnify and hold Provider harmless from claims arising from inaccurate information provided by Patient or third-party instructions.

Dispute Resolution and Governing Law

The parties shall first attempt good faith negotiation; unresolved disputes shall be submitted to binding arbitration in the state of: . This Agreement is governed by the laws of the governing state specified above.

Authorization, Representations and Entire Agreement

Each party represents that it has the authority to enter this Agreement. This Agreement, together with any written attachments and the patient intake information completed above, constitutes the entire agreement between the parties and supersedes prior representations.

Patient confirms that the information provided is accurate to the best of their knowledge and that they understand the scope of the consultation, fees and patient responsibilities outlined above.

HIPAA Authorization Acknowledgment

I authorize Provider to use and disclose my protected health information for the purposes described in this agreement, including consultation, billing and treatment coordination. I understand I may revoke this authorization in writing except to the extent that Provider has already relied upon it.

I consent to release of records to third parties involved in my care:

Effective Date

Effective Date of this Agreement:

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