Healthcare Coordinated Services Agreement

HEALTHCARE COORDINATED SERVICES AGREEMENT

This Healthcare Coordinated Services Agreement (the Agreement) is entered into by the parties identified below for the purpose of coordinating and facilitating health care and related support services for the Patient. Patient Name: Coordinating Organization: Effective Date:

1. Parties and Purpose

Patient Name (Client):

Coordinating Organization (Provider):

Purpose: The Provider will coordinate medically necessary services, referrals, appointments, and communications among health care providers, social services, and the Patient to support continuity of care in accordance with this Agreement.

2. Definitions

"Coordination Services" means scheduling, referral management, care planning, information exchange with consent, and related activities described in Section 3. "Protected Health Information (PHI)" has the meaning given by applicable privacy law.

3. Scope of Services

4. Responsibilities of the Coordinating Organization

The Provider will perform coordination services reasonably necessary to implement the care plan, which may include:

Develop and maintain an individualized care plan and update it with the Patient as needed.
Arrange and track referrals to specialists, community supports, and ancillary services.
Communicate with treating providers, with Patient consent, to share relevant clinical information for coordination.
Monitor adherence to the care plan and follow up on missed appointments or any gaps in care.

5. Responsibilities of the Patient / Client

The Patient agrees to: provide accurate medical and insurance information; participate in care planning; keep scheduled appointments or notify Provider of cancellations; and provide informed consent to disclosure of PHI as necessary for coordination.

I will provide accurate information and inform Provider of changes to my health status or insurance.
I will participate in the care planning process and follow agreed recommendations when feasible.

6. Authorization to Use and Disclose Protected Health Information

By signing this Agreement, the Patient authorizes the release and exchange of PHI as necessary to coordinate services between the Provider, other health care providers, payors, and community service agencies identified in the care plan. This includes clinical records, appointment information, medication lists, and referral outcomes, but does not authorize disclosure for unrelated research or marketing.

Scope of authorized PHI:

I authorize release of my PHI for the purposes of care coordination as described above.

7. HIPAA Privacy Acknowledgment

The Patient acknowledges that the Provider will use and disclose PHI in accordance with applicable privacy laws and that a written notice of privacy practices has been provided or made available. The Patient has the right to revoke this authorization in writing except to the extent actions have been taken in reliance on it.

I acknowledge receipt of the Provider's privacy practices as described above.

8. Fees, Billing and Payment Authorization

Fee Arrangement: The Provider's services may be covered by insurance, provided at no additional charge by contract, or billed to the Patient as set forth below. The Patient authorizes the Provider to bill the listed insurer and to receive payment on the Patient's behalf when applicable.

Bill insurance or third-party payor
No charge to Patient for coordination services
Patient responsible for fees not covered by insurance

9. Term, Termination and Modification

Term: This Agreement begins on the Effective Date and continues until terminated by either party with fifteen (15) days' written notice, unless otherwise specified below.

Termination Reason / Special Terms:

10. Confidentiality, Security and Recordkeeping

The Provider will implement administrative, physical, and technical safeguards to protect PHI. Records created as part of coordination services will be retained consistent with applicable law and Provider policy. The Provider will not disclose PHI except as authorized by this Agreement or as required by law.

11. Limitation of Liability and Indemnification

The Provider's role is coordination and facilitation and not the direct provision of medical treatment unless otherwise agreed. The Provider does not guarantee clinical outcomes. To the extent permitted by law, each party releases the other from liability for incidental errors in coordination and agrees to indemnify for claims arising from gross negligence or willful misconduct.

12. Dispute Resolution

The parties will attempt in good faith to resolve disputes arising under this Agreement through negotiation. If unresolved, disputes will be resolved by binding arbitration or in the courts as selected by the Provider if arbitration is not applicable under law.

13. Patient Medical and Insurance Information

14. Insurance Information

15. Authorization Expiration

This authorization to use and disclose PHI shall expire on: or upon the occurrence of the following event:

16. Withdrawal of Authorization

The Patient may revoke this authorization at any time by delivering written notice to the Provider. Revocation will not affect disclosures made in reliance on this authorization prior to the Provider's receipt of the revocation.

17. Guardian or Authorized Representative

If the Patient is a minor or lacks capacity, a legal guardian or authorized representative may sign. Relationship to Patient:

Legal authority to sign (if applicable):

18. Certifications

By signing below, the Patient or authorized representative certifies that the information provided in this Agreement is accurate to the best of their knowledge, that they have read and understand the terms herein, and that they authorize the Provider to coordinate care as described. The Patient understands they may revoke this authorization in writing at any time, subject to the limitations described above.

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