Healthcare Contract Terms

HEALTHCARE CONTRACT TERMS

This Healthcare Contract Terms ("Agreement") is entered into by and between Provider Name: and Client / Patient Name: . Effective Date: . These parties agree to the terms set forth below.

1. Patient Information

2. Insurance Information

3. Medical History & Current Status

4. Scope of Services

Provider will furnish the services described below in accordance with professional standards of care. Services to be provided:

5. Compensation, Billing, and Payment

Fees: Patient agrees to pay Provider the fees set forth below for services rendered. Fee schedule or rate:

Patient authorizes billing to insurance and assignment of benefits where applicable: I authorize Provider to bill my insurer and accept assignment of benefits.

6. Confidentiality and Privacy (HIPAA Compliance)

Provider will maintain the confidentiality of protected health information in accordance with applicable law. Patient acknowledges receipt of Provider's Notice of Privacy Practices and consents to the use and disclosure of health information for treatment, payment and healthcare operations as necessary to fulfill this Agreement.

Patient acknowledges: I have received or been offered the Provider's Notice of Privacy Practices and consent to uses and disclosures as stated.

7. Term, Termination, and Withdrawal

Term: This Agreement remains in effect from the Effective Date until services are completed or terminated as provided herein. Either party may terminate this Agreement upon written notice to the other party. Provider may terminate immediately for failure to pay, material breach, or when continued provision of services would violate professional or legal obligations.

Patient retains the right to withdraw consent and discontinue services at any time; however, Patient remains responsible for payment for services already rendered and any non-cancellable obligations incurred by Provider prior to termination.

8. Risk, Liability, and Indemnification

Provider will perform services in a competent professional manner. Except as prohibited by law, Patient agrees to indemnify and hold Provider harmless from claims arising out of Patient's failure to provide complete and accurate information, and from the negligence of third parties. Provider's liability for damages is limited to direct damages and shall not exceed the amounts paid by Patient for the specific services giving rise to the claim.

9. Dispute Resolution

The parties agree to attempt good-faith negotiation to resolve disputes arising under this Agreement. If unresolved within 60 days, disputes shall be submitted to binding arbitration under the rules agreed upon by the parties, and judgment upon the award rendered may be entered in any court of competent jurisdiction. Each party will bear its own costs unless the arbitrator directs otherwise.

10. Notices

Notices under this Agreement must be in writing and delivered to the addresses below. Provider Notice Address:

Patient Notice Address:

11. Amendments; Severability; Governing Law

This Agreement may be amended only by a written instrument signed by both parties. If any provision is held unenforceable, the remainder of the Agreement will remain in full force and effect. This Agreement is governed by the laws of the state agreed by the parties:

12. Authorization and Duration of Consent

Patient hereby authorizes Provider to provide the services described herein. This authorization shall expire on:

13. Certifications and Acknowledgments

By signing below, Patient certifies that the information provided is true and complete to the best of Patient's knowledge, that Patient has had the opportunity to ask questions and receive answers regarding the services, risks, benefits and alternatives, and that Patient consents to the provision of care under the terms of this Agreement.

I certify the above statements and accept the terms of this Agreement.

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