Healthcare Contract with HIPAA

HEALTHCARE SERVICE AGREEMENT AND HIPAA AUTHORIZATION

This Healthcare Service Agreement and HIPAA Authorization (the Agreement) is entered into by and between Provider Name: and Patient Name: . The parties agree to the terms set forth below governing the provision of healthcare services, financial responsibility, and authorization for the use and disclosure of protected health information.

Patient Information

Emergency Contact

Insurance Information

Medical History (Relevant)

Scope of Services and Financial Terms

Provider will provide the following services:

Estimated fees for services, if applicable: . Patient is responsible for copayments, coinsurance, deductibles and non-covered services. Patient authorizes direct billing to the insurer but remains financially responsible for balances not paid by insurance.

Assignment of Benefits and Payment Authorization: Patient hereby authorizes Provider to submit claims to Patient's insurance and assigns to Provider any insurance benefits payable for services rendered. Patient authorizes release of insurance information necessary to process claims.

HIPAA AUTHORIZATION AND PRIVACY ACKNOWLEDGMENT

Authorization to Use and Disclose Protected Health Information (PHI): Patient hereby authorizes Provider to use and disclose PHI as necessary for treatment, payment, and healthcare operations. PHI includes but is not limited to: medical records, billing records, test results, and demographic information.

Purpose of Disclosure: PHI may be used and disclosed for the purposes of diagnosis, treatment, referral, billing and payment, coordination of care, quality assurance, and as required by law. PHI may also be disclosed to insurers, other healthcare providers, and persons involved in the patient's care as authorized below.

Entities Authorized to Receive or Disclose PHI (check all that apply):

Expiration of Authorization: This authorization will expire on unless earlier revoked in writing. If no date is provided, this authorization will expire one year from the date of signature.

Right to Revoke: Patient may revoke this authorization at any time by providing written notice to Provider Name: . Revocation will not affect disclosures already made in reliance on this authorization.

Redisclosure: Information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations. Provider will make reasonable efforts to limit redisclosure in accordance with applicable law.

Patient Consent and Certifications

Consent to Treatment: Patient consents to such examinations, treatments, procedures and diagnostic tests as reasonably recommended by Provider. Patient acknowledges that no guarantees have been made regarding the results of treatment.

Financial Responsibility: Patient certifies that the information provided herein is accurate and complete. Patient agrees to be financially responsible for all charges for services rendered by Provider that are not paid by insurance or a third party.

Minors and Guardians: If the patient is a minor or legally incapable of executing this Agreement, the undersigned guardian or legal representative certifies that they are authorized to consent to treatment and execute this authorization on behalf of the patient and accepts financial responsibility.

Termination: Either party may terminate this Agreement upon written notice. Termination does not affect obligations incurred prior to termination, including payment for services rendered and use/disclosure of PHI as permitted by this authorization.

Governing Law and Severability: This Agreement shall be governed by applicable law. If any provision is held invalid, the remaining provisions shall remain in full force and effect.

Certification

By signing below, I certify that I am the patient or the patient's authorized representative, that I have read and understand this Agreement, that the information I have provided is true and accurate to the best of my knowledge, and that I authorize the uses and disclosures described above.

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