Healthcare Contract Expansion

HEALTHCARE CONTRACT EXPANSION

Parties and Effective Date

This Healthcare Contract Expansion (the Expansion) is entered into by and between:

Provider Name:    Provider Tax/ID (if applicable):

Patient Name:    Patient DOB:

Effective Date of Expansion:

Purpose and Scope

Purpose: The parties hereby agree to expand the services provided under the existing healthcare agreement between Provider and Patient to include the additional services and modifications described below. This Expansion incorporates and amends the original agreement only to the extent expressly set forth herein; all other terms remain in full force and effect.

Patient Information

Insurance and Billing

Billing Adjustments: The fees and rates applicable to the expanded services will be as follows: Fee Schedule:

Patient Responsibility (co-payments, deductibles, non-covered services):

Medical History and Current Condition

Risks, Benefits, and Consent

The Provider has explained the nature of the expanded services, including material risks, potential benefits, and reasonable alternatives. Patient acknowledges understanding of these risks and benefits and consents to receive the expanded services described above.

I hereby consent to the expanded services as described in this Expansion and acknowledge receipt of information regarding risks and benefits.

Right to Withdraw: Patient has the right to withdraw consent at any time prior to or during the provision of services, subject to reasonable notice and the Provider's duty to ensure safe transition of care.

Privacy, Authorization, and Release

HIPAA Authorization: Patient authorizes the Provider to use and disclose protected health information as necessary to provide the expanded services, to bill and collect payment, and to coordinate care with other providers and payers as required.

I acknowledge receipt of the Provider's Notice of Privacy Practices and authorize the use and disclosure of my health information as set forth above.

Representations, Indemnity, and Termination

Representations: Each party represents that it has authority to enter into this Expansion and that the information provided herein is true and complete to the best of its knowledge.

Indemnity: To the fullest extent permitted by law, Patient agrees to indemnify and hold harmless Provider from claims arising out of Patient's false statements, failure to disclose medical information material to treatment, or nonpayment of patient-responsible charges. Provider agrees to indemnify Patient for negligent acts of Provider personnel in providing the expanded services.

Termination: This Expansion may be terminated by either party for material breach after thirty (30) days' written notice and opportunity to cure, or immediately for reasons relating to patient safety or applicable law.

Dispute Resolution

The parties agree to attempt good faith negotiation of disputes arising under this Expansion. If unresolved, disputes shall be submitted to mediation, and if mediation fails, to binding arbitration in accordance with the rules agreed by the parties. This clause does not limit the right to seek injunctive relief.

Miscellaneous

Integration: This Expansion, together with the original agreement, constitutes the entire understanding between the parties with respect to the subject matter herein and supersedes any prior agreements to the extent expressly modified.

Amendment: Any amendment to this Expansion must be in writing and signed by both parties.

Acknowledgment

By signing below, the parties acknowledge that they have read and understand this Healthcare Contract Expansion, agree to its terms, and have the authority to execute and bind their respective parties.

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