Healthcare Diagnostic Center Agreement

Healthcare Diagnostic Center Agreement

PARTIES AND EFFECTIVE DATE

Diagnostic Center Name:

Patient Name:

Agreement Effective Date:

PATIENT CONTACT & IDENTIFICATION

INSURANCE AND BILLING AUTHORIZATION

Primary Insurance Provider:

Policy / ID Number:    Group Number:

Subscriber Name (if different):

By signing this Agreement, Patient authorizes the Diagnostic Center to bill insurance and to release necessary information for claims processing. Patient also agrees to be responsible for any balance not covered by insurance, including deductible, copayment, coinsurance, and non-covered services.

Assignment of Benefits: I assign benefits payable for services rendered to the Diagnostic Center and permit payments to be made directly to the Diagnostic Center.

MEDICAL HISTORY & SPECIMEN INFORMATION

Specimen or sample collection requirements and special handling instructions will be communicated at scheduling. Patient agrees to follow fasting, medication withholding, or other preparatory instructions; failure to comply may result in test cancellation or rescheduling and possible additional fees.

SERVICES, RISKS, AND LIMITATIONS

The Diagnostic Center will perform diagnostic tests as ordered by the referring provider or requested by Patient. Tests may include laboratory analysis, imaging, physiologic studies, or other procedures. Patient acknowledges that all tests have inherent limitations and that no test can guarantee detection of every condition.

Risks: Certain diagnostic procedures may carry risks including, but not limited to, allergic reaction, bruising, infection, radiation exposure, or discomfort. Patient acknowledges receipt of verbal or written explanation of the procedure and potential risks when applicable and their opportunity to ask questions.

RESULTS, RELEASE OF INFORMATION, AND RECORDS

Patient authorizes the Diagnostic Center to release results and diagnostic reports to the referring provider and to other providers designated below for continuity of care:

HIPAA Authorization and Privacy Acknowledgment: I acknowledge that I have received or been offered the Diagnostic Center's Notice of Privacy Practices and authorize the use and disclosure of my protected health information for treatment, payment, and healthcare operations as described.

PAYMENT TERMS, FEES, AND CANCELLATION

Patient agrees to pay applicable charges for services rendered. If insurance coverage is denied or payment is not received from an insurer within a commercially reasonable time, Patient is responsible for payment. The Diagnostic Center may impose reasonable fees for late cancellations or missed appointments; Patient agrees to the stated cancellation policy at the time of scheduling.

Billing Statements: Statements will be sent to the address on file. Unpaid balances may be referred to collections in accordance with Diagnostic Center policy.

INDEMNIFICATION; LIMITATION OF LIABILITY

To the fullest extent permitted by law, Patient agrees to indemnify and hold harmless the Diagnostic Center, its employees, contractors and agents from claims arising out of Patient's failure to disclose relevant medical history or failure to follow pre-test instructions. The Diagnostic Center's liability for any claim relating to services rendered is limited to direct damages up to the amount paid by or on behalf of Patient for the specific service, and the Diagnostic Center shall not be liable for consequential, incidental, or punitive damages.

TERMINATION AND MODIFICATION

This Agreement may be amended in writing by mutual agreement. The Diagnostic Center may terminate or suspend services for nonpayment or for failure to comply with required preparatory instructions or policies. Termination of this Agreement does not relieve Patient of financial obligations for services already rendered.

AUTHORIZATION DURATION

This authorization to provide diagnostic services and to release information is valid until: unless earlier revoked in writing. Revocation will not affect disclosures made prior to receipt of revocation.

PATIENT CERTIFICATION AND CONSENT

By signing below, Patient certifies that the information provided in this Agreement is accurate and complete to the best of Patient's knowledge, that Patient consents to the diagnostic tests and related services described herein, and that Patient has had the opportunity to ask questions and receive answers regarding the procedures, risks, benefits, alternatives, and post-procedure care. Patient further authorizes the Diagnostic Center to maintain records of services provided.

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