Healthcare CoreCare Contract

HEALTHCARE CORECARE CONTRACT

Parties and Effective Date

This Healthcare CoreCare Contract ("Agreement") is entered into between Provider Name: and Patient Name: . Effective Date:

Contract Recitals

Provider operates a primary and ongoing care practice under the name CoreCare and offers continuous care, care coordination, and access to designated clinicians. Patient seeks to obtain such CoreCare services under the terms and conditions set forth in this Agreement.

Patient Information

Insurance Information

Medical History (Relevant)

Scope of CoreCare Services

Provider will deliver continuous primary-care services, including but not limited to scheduled visits, same-day access as clinically appropriate, care coordination with specialists, medication management, preventive health planning, and telehealth services where available. Specific exclusions: emergency stabilization and inpatient hospital procedures are not part of CoreCare services unless separately agreed.

Fees, Billing and Payment

Patient agrees to pay the fees set forth below. Fees for CoreCare services are independent of insurance reimbursements unless otherwise specified by a separate assignment agreement.

Late payments may result in suspension of non-emergent services after reasonable notice. Patient remains responsible for all unpaid fees through the date of termination.

Insurance Assignment and Billing Authorization

Patient authorizes Provider to submit claims to Patient's insurance as necessary for services rendered and to apply any insurance payments to outstanding charges. Patient may revoke this authorization in writing; revocation does not affect payments for services already rendered.

Patient Responsibilities

Patient agrees to provide complete and accurate medical history and to inform Provider of any changes in health status, insurance, or contact information. Patient must attend scheduled appointments or provide timely notice of cancellation. Patient is responsible for fees for missed appointments in accordance with Provider policy.

Consent to Treatment and Medical Decision Making

Patient consents to such diagnostic and therapeutic procedures as are reasonably necessary in the professional judgment of Provider. Patient acknowledges the right to be informed of treatment alternatives, risks, and benefits and retains the right to refuse treatment at any time. Minor patients require guardian signature below for consent.

Privacy, Confidentiality and HIPAA Acknowledgment

Provider maintains patient health information in accordance with applicable privacy laws. Patient acknowledges receipt of Provider's notice of privacy practices and consents to use and disclosure of protected health information for treatment, payment, and health care operations as permitted by law.

Authorization for Release of Records

Patient authorizes Provider to release medical records to other treating providers, family members, or payors as necessary for coordination of care and claims processing, except where otherwise restricted by Patient in writing.

Termination

Either party may terminate this Agreement upon thirty (30) days' written notice. Provider may terminate sooner for nonpayment, material breach, or behaviors that threaten staff safety. Patient remains responsible for fees incurred through termination date.

Limitation of Liability and Indemnification

Provider shall perform services consistent with applicable standards of care. To the extent permitted by law, neither party shall be liable for incidental, consequential, or punitive damages. Patient agrees to indemnify Provider for third-party claims arising from Patient's misuse of services or false information.

Dispute Resolution and Governing Law

Parties agree to first attempt resolution through good-faith negotiation. If unresolved, disputes shall be resolved by binding arbitration in the Provider's principal place of business under the rules of a recognized arbitration body. This Agreement shall be governed by the substantive law of the state where Provider principally practices.

Miscellaneous

This Agreement constitutes the entire agreement between the parties regarding CoreCare services and supersedes prior agreements. Amendments must be in writing and signed by both parties. If any provision is found unenforceable, remaining provisions shall remain in effect.

Acknowledgments

By signing below, Patient and Provider acknowledge that they have read this Agreement, understand its terms, and agree to be bound by them.

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