Healthcare Crisis Contract

HEALTHCARE CRISIS CONTRACT

This Healthcare Crisis Contract (the Agreement) is entered into on between Patient Name: Date of Birth: and Provider Name: .

1. Purpose and Scope of Services

Provider agrees to render crisis intervention, stabilization, coordination, and follow-up services (Crisis Services) to Patient as described in this Agreement. Crisis Services may include assessment, short-term counseling, crisis planning, referral and coordination with emergency services, and, when necessary, facilitation of transport to an appropriate acute care facility.

2. Patient Information

3. Insurance and Billing

4. Medical and Crisis History

5. Crisis-Specific Information

Consent for specific crisis interventions (check all that apply):

Consent to emergency transport to an acute care facility if clinically indicated

Consent to administration of short‑term psychotropic medication as clinically indicated during crisis stabilization

Consent to limited, clinically necessary physical interventions to ensure safety when less restrictive measures have failed

6. Authorization to Share Information

Patient authorizes Provider to disclose and receive protected health information (PHI) to/from emergency responders, hospitals, behavioral health providers, and other relevant service agencies for purposes of crisis assessment, treatment, transport, and coordination of care. Such disclosures are limited to the minimum necessary information to accomplish the stated purpose.

7. Payment, Fees and Collections

Patient agrees to be responsible for co-payments, deductibles, and any non-covered services. Provider will bill insurance when authorized. If Patient is uninsured or elects not to bill insurance, fees for crisis services will be assessed in accordance with Provider's fee schedule.

8. Risks, Limitations and Consent

Patient acknowledges that crisis intervention carries risks, including but not limited to transient increases in distress, unintended disclosure of sensitive information during coordination of care, and the possibility that emergency services may deem involuntary measures necessary. Patient consents to the provision of Crisis Services and understands the limitations and potential outcomes.

Patient retains the right to withdraw consent at any time by written notice to Provider, except when withdrawal would endanger Patient or others or as otherwise required by applicable law (for example, when Provider is required to act to prevent imminent harm).

9. Confidentiality and HIPAA Acknowledgment

Patient acknowledges receipt of Provider's privacy practices and understands that PHI will be handled in accordance with applicable privacy laws. Patient understands exceptions to confidentiality include mandatory reporting, imminent risk of harm, and disclosures required for coordination of emergency care.

I acknowledge that I have received and understand the Provider's privacy practices as described above.

10. Liability, Indemnification, and Dispute Resolution

Provider will exercise reasonable clinical judgment in delivery of Crisis Services. To the fullest extent permitted by law, Provider's liability for claims arising out of services provided under this Agreement is limited to actual direct damages and does not include punitive, incidental or consequential damages. Patient agrees to indemnify and hold harmless Provider for claims arising from Patient's actions that are outside the scope of Provider's services.

Any dispute arising under this Agreement shall be governed by the laws of the state where Provider's principal office is located and, if not resolved informally, submitted to binding arbitration in accordance with local arbitration rules unless otherwise prohibited by law.

11. Term and Termination

This Agreement shall remain in effect until the Authorization Expiration Date identified above, until services are completed, or until terminated by either party with written notice. Termination does not relieve Patient of obligations to pay fees incurred prior to termination.

12. Notices

Notices required under this Agreement shall be provided to the addresses listed in Section 2 of this Agreement or to other addresses provided in writing by the parties. Notice is effective upon deposit with the U.S. mail or upon electronic transmission if confirmed by the sender.

13. Acknowledgment and Certification

By signing below, Patient and Provider certify that they have read and understand this Agreement, that Patient's questions about the nature and purpose of the Crisis Services have been answered, and that Patient consents to treatment under the terms and conditions set forth herein. If Patient is signing on behalf of another individual, the signer certifies they have legal authority to do so and must describe their relationship.

Sign Now