Healthcare Customer Agreement

HEALTHCARE CUSTOMER AGREEMENT

This Healthcare Customer Agreement ("Agreement") is entered into between Provider Name: and Patient Name: . The parties agree that the terms and conditions set forth below will govern the provision of healthcare services, billing, privacy, and other related matters.

1. Patient Information

Date of Birth: / /

Male Female Other

2. Emergency Contact

3. Insurance Information

Subscriber Date of Birth: / /

4. Medical History

5. Agreement for Services, Billing and Payment

Acceptance: Patient requests and authorizes Provider to provide healthcare services as clinically indicated. Patient acknowledges that no specific outcome is guaranteed and that medical opinions, procedures, and treatments will be provided in accordance with professional standards.

Financial Responsibility: Patient is responsible for all charges for services not covered by insurance, including co-payments, deductibles, co-insurance, and non-covered services. Patient agrees to pay charges when billed. If insurance denies payment, Patient remains responsible for payment in full. Patient hereby authorizes assignment of benefits to Provider and directs payment of benefits to Provider when applicable.

Billing and Collection: Unpaid balances may be referred to collection agencies and Patient will be responsible for collection costs, including reasonable attorney fees and court costs, as permitted by law. Provider may report account status to credit reporting agencies where allowed.

Cancellation / No-Show Policy: Patient agrees to provide timely notice of cancellations. Provider may assess fees for missed appointments or late cancellations in accordance with Provider policy; Patient agrees to pay such fees unless excused for good cause.

6. Consent, Release and Authorizations

Consent to Treatment: Patient consents to routine medical evaluation, diagnostic procedures, treatment, and minor procedures as recommended by Provider. Patient has the right to ask questions and to refuse treatment except in emergencies where Patient is unable to consent and immediate treatment is necessary to preserve life or prevent serious harm.

Authorization to Release Information: Patient authorizes Provider to release medical information necessary for treatment, payment, or healthcare operations to insurers, other healthcare providers, and as required by law. Patient specifically authorizes release of information relating to mental health, communicable diseases, or substance use disorder to the extent necessary for billing and care coordination.

Assignment of Benefits: Patient assigns to Provider any insurance and other third-party benefits payable for services rendered. Patient authorizes Provider to act on Patient's behalf in communicating with payers, to appeal denials, and to obtain payment directly. Patient will cooperate with Provider in completing forms and providing information for claims.

Authorization Expiration: This authorization to release information and assignment of benefits expires on / / unless earlier revoked in writing.

7. Privacy and HIPAA Acknowledgment

Notice of Privacy Practices: Patient acknowledges receipt of Provider's Notice of Privacy Practices describing uses and disclosures of protected health information and Patient's rights. Patient may request restrictions and confidential communications as provided under applicable law.

Acknowledgment: I acknowledge that I have received or been offered a copy of the Notice of Privacy Practices.

8. Telehealth and Electronic Communications

Telehealth Consent: Patient consents to telehealth consultations when offered, understands the benefits and limitations, and accepts potential privacy risks inherent in electronic communications. Patient may revoke consent at any time in writing.

Electronic Contact: Patient consents to receive appointment reminders, billing notices, and clinical information via phone, text message, or email at the contact information provided above unless Patient instructs otherwise in writing.

9. Minors and Guardians

If Patient is a minor or is otherwise unable to consent, the undersigned represents that they are the parent or legal guardian authorized to consent to treatment and execute this Agreement. Guardian agrees to accept financial responsibility and to provide documentation of authority upon request.

10. Limitation of Liability; Dispute Resolution

Limitation of Liability: Except as prohibited by law, Provider's liability for damages arising out of care provided under this Agreement shall be limited to direct damages and shall not include punitive, exemplary, or consequential damages.

Governing Law and Dispute Resolution: This Agreement shall be governed by the laws of the state in which the services are provided. Disputes shall be resolved by binding arbitration to the extent permitted by law, except where prohibited, and each party consents to the forum and jurisdiction specified by Provider policies.

11. Additional Certifications and Notices

Accuracy of Information: Patient certifies that the information provided on this form is true and correct to the best of Patient's knowledge. Patient agrees to promptly notify Provider of any changes to insurance, contact information, or health status that may affect care or billing.

Photographs/Recordings: Patient authorizes photographs or recordings for medical record, identification, or clinical purposes only and understands that separate authorization is required for use in public presentations or marketing unless otherwise agreed in writing.

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