Healthcare Contract & LOR

HEALTHCARE CONTRACT AND LETTER OF REFERRAL

Parties and Recitals

This Agreement and Letter of Referral ("Agreement") is entered into between Referring Organization: and Receiving Provider/Facility: .

Recitals: Referring Organization wishes to refer Patient identified below to Receiving Provider for consultation, treatment, or services described herein, and Receiving Provider agrees to provide such services under the terms and conditions set forth in this Agreement.

Patient Information

Date of Birth:    Gender:    Phone:

Insurance Information

Medical History and Current Status

Referral Details and Scope of Services

Reason for Referral:

Urgency:    Preferred appointment within:

Lab results    Imaging studies    Clinical notes    Other:

Payment, Billing and Responsibility

Payment and Billing: Receiving Provider shall bill applicable insurance and/or patient directly for services rendered. Referring Organization shall not be responsible for fees unless specifically agreed in writing. Any agreed payment arrangement must be stated here:

Prior Authorizations: Referring Organization represents that, to the best of its knowledge, any prior authorizations required have been obtained or are the responsibility of the party identified:

HIPAA Compliance and Release Authorization

Confidentiality and PHI: Both parties shall comply with all applicable laws and regulations governing protected health information. The parties agree to use and disclose PHI only as permitted by law and this Agreement and shall implement administrative, physical, and technical safeguards to protect PHI.

Patient Authorization to Release Records: I, Patient Name: , hereby authorize Referring Organization to release medical records, including protected health information, to Receiving Provider for the purpose of consultation and continued care. This authorization includes release of mental health, substance use, and HIV-related information if relevant.

Authorization Expiration Date: . If no date is provided, this authorization will remain valid for 90 days from the date of referral.

Patient Acknowledgment: I acknowledge that my medical information will be shared with the Receiving Provider and that I have the right to revoke this authorization in writing except to the extent that action has been taken in reliance on it.

Representations, Warranties, Indemnity and Termination

Representations and Warranties: Each party represents that it is duly authorized to enter into this Agreement and that it will perform its duties in accordance with applicable professional standards and laws.

Indemnification: Each party agrees to indemnify and hold harmless the other party for claims arising from the indemnifying party’s negligence or willful misconduct in the performance of this Agreement, subject to applicable law and professional liability limitations.

Termination: Either party may terminate this Agreement upon thirty (30) days' written notice to the other party, or immediately for cause upon material breach that is not cured within a reasonable period.

Records Retention and Ownership: Medical records and original clinical documentation remain the property of the creating entity, except where required otherwise by law. Copies transmitted pursuant to this referral shall be retained as required by law.

Governing Law: This Agreement shall be governed by the laws of the jurisdiction where Referring Organization is located, without regard to conflict of law principles.

Additional Terms

Certification and Acknowledgement

By signing below, each party certifies that the information provided is true and accurate to the best of their knowledge, that they have authority to enter into this Agreement, and that they will comply with all applicable laws and professional standards in performing their obligations.

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