Healthcare Contract Executed

HEALTHCARE SERVICES CONTRACT (EXECUTED)

This Healthcare Services Contract (the Agreement) is made effective as of by and between Provider Name: and Patient Name: .

1. Patient Information

Male Female Other Prefer not to say

2. Emergency Contact

3. Insurance Information

4. Medical History

5. Scope of Services

Provider shall provide the services described below to Patient in accordance with accepted professional standards. Description of services:

6. Financial Terms

Patient agrees to pay Provider for services rendered in accordance with Provider's fee schedule. Insurance benefits are assigned to Provider where permitted; Patient remains ultimately responsible for all charges not covered by insurance, including co-payments, deductibles, and non-covered services.

Billing practices: unpaid balances are subject to interest and collection as provided in Provider policy. Payment disputes must be submitted in writing within thirty (30) days of the date of the invoice.

7. Consent to Treatment & HIPAA Authorization

Patient hereby authorizes Provider and Provider's authorized personnel to perform medical services, diagnostic procedures, and related care as reasonably necessary. Patient acknowledges that no guarantee has been made as to the results of any treatment.

Patient authorizes the use and disclosure of Protected Health Information for treatment, payment, and healthcare operations consistent with applicable privacy laws. Patient authorizes Provider to release medical information to insurers, referring providers, and as required by law.

Patient acknowledges the right to revoke this authorization in writing, except to the extent that Provider has already relied upon it. Revocation does not affect disclosures made prior to receipt of a revocation.

8. Risks, Benefits, and Alternatives

Patient understands that all clinical procedures involve potential risks and benefits. Provider has explained the nature of the proposed treatment, potential material risks, anticipated benefits, and reasonable alternatives, including no treatment, and Patient has had the opportunity to ask questions.

Patient acknowledges receiving this information and consents to proceed with the described treatment subject to the terms of this Agreement.

9. Term, Termination, and Amendment

This Agreement commences on the Effective Date and continues until the completion of services or earlier termination. Either party may terminate for material breach that remains uncured thirty (30) days after written notice. Termination does not relieve Patient of financial obligations for services rendered prior to termination. Any amendment to this Agreement must be in writing and signed by both parties.

10. Representations, Indemnification, and Liability

Each party represents that it has authority to enter into this Agreement. Patient shall indemnify and hold harmless Provider from claims arising from Patient's failure to provide accurate medical history or to follow medical advice, except to the extent caused by Provider's gross negligence or willful misconduct. Provider's liability for any claim arising under this Agreement shall be limited to direct damages and shall not include punitive, special, consequential, or incidental damages to the extent permitted by law.

11. Dispute Resolution and Governing Law

The parties agree to attempt in good faith to resolve disputes informally. If unresolved, disputes shall be resolved by binding arbitration under the rules agreed at the time of dispute. This Agreement is governed by the substantive laws of the state in which Provider maintains its principal place of business, without regard to conflict of laws principles.

12. Miscellaneous

This Agreement constitutes the entire agreement between the parties with respect to the subject matter and supersedes prior agreements and understandings. If any provision is found invalid, the remaining provisions shall remain in effect. Neither party may assign this Agreement without the prior written consent of the other, except Provider may assign to an affiliate or successor in interest.

13. Certifications and Acknowledgments

By signing below, Patient and Provider certify that the information provided in this form is true and complete to the best of their knowledge, that they have the requisite authority to enter into this Agreement, and that they have read and understand the terms of this Agreement.

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