Healthcare Contract Checked

Healthcare Contract Checked

This Healthcare Contract Checked confirms that the undersigned parties have reviewed and verified the material terms of the healthcare services agreement to which this verification is affixed. Client Name: Provider Name: Effective Date:

Patient Information

Male    Female    Non-binary    Other

Insurance Information

Medical History

Contract Checklist (Provider Verifies)

The provider certifies that the following elements of the underlying healthcare services agreement have been reviewed with the patient and are accurate as recorded below.

Service description documented and explained to patient
Fee schedule and patient financial responsibility provided
Insurance eligibility and benefits verified
Informed consent for proposed treatment obtained where applicable
Notice of privacy practices provided and acknowledged
Medication reconciliation completed
Allergies and adverse reactions verified
Advance directives / surrogate decision-maker status reviewed and documented
Billing, collections, and insurance assignment terms explained
Follow-up and emergency contact plan provided

Terms and Conditions

1. Services: Provider agrees to deliver the healthcare services described in the attached services agreement or plan of care. Services shall be provided in accordance with accepted standards of care and applicable professional regulations.

2. Payment and Insurance: Patient remains primarily responsible for payment of all charges for services rendered. Provider will bill insurance as a courtesy where applicable; verification of benefits does not guarantee payment by an insurer. Patient agrees to pay co-payments, deductibles, co-insurance, and any balances not covered by insurance.

3. Consent to Treat: Patient confirms that informed consent has been obtained for treatments and procedures requiring consent. Patient retains the right to withdraw consent at any time consistent with clinical safety; withdrawal of consent may affect the ability to provide certain services.

4. Privacy and Release of Information: Patient acknowledges receipt of the provider's privacy notice and authorizes release of protected health information to the extent necessary for treatment, payment, and healthcare operations, or as otherwise permitted or required by law. Authorization to release information for other purposes must be provided in writing.

5. Limitation of Liability and Indemnity: To the fullest extent permitted by law, neither party shall be liable to the other for indirect, incidental, special, or consequential damages. Patient agrees to indemnify and hold harmless Provider against third-party claims arising from patient-provided misinformation or failure to follow reasonable instructions.

6. Termination: Either party may terminate services upon providing reasonable notice, subject to applicable clinical obligations to ensure safe transfer of care. Outstanding obligations, including payment for services rendered prior to termination, survive termination.

7. Governing Law and Dispute Resolution: This verification and any underlying agreement shall be governed by the laws of the state in which services are provided. The parties agree to attempt informal resolution of disputes in good faith prior to initiating formal proceedings.

8. Amendment and Severability: Any modification to the underlying agreement must be in writing and signed by both parties. If any provision is held unenforceable, remaining provisions shall continue in full force and effect.

9. Acknowledgment of Review: By signing below, the parties confirm that they have reviewed the material terms listed on this document and the underlying services agreement, that the checklist items marked are accurate, and that the patient has had an opportunity to ask questions and receive answers. Authorization expiration date:

HIPAA / Privacy Acknowledgment

Patient acknowledges receipt of the Notice of Privacy Practices and consents to the use and disclosure of protected health information for the purposes described therein. Patient consents to voice, electronic, and written communications regarding appointment reminders, billing, and care coordination unless otherwise indicated.

Patient acknowledges receipt of privacy notice and authorizes communications as indicated above

Provider Certification

The undersigned provider representative certifies that the items checked on this form reflect the provider's review and verification of the patient's contract-related information and that supporting documentation is maintained in the medical record.

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