Healthcare Disclaimer

HEALTHCARE DISCLAIMER

Provider and Visit Information

Provider Name:    Location/Clinic:

Date of Visit:    Service/Procedure:

Patient Information

Insurance Information

Medical History (Relevant)

Disclaimer and Limitations

This Healthcare Disclaimer (the "Disclaimer") governs the relationship between Provider and Patient for the services identified above. Patient acknowledges and agrees that Provider has explained the nature and scope of the services and that Patient has had an opportunity to ask questions concerning the following limitations and acknowledgments.

1. No Guarantee: Patient understands that Provider does not guarantee results, cures, or outcomes. Medical care involves inherent risks and variability in response. Provider makes no warranty, express or implied, regarding the efficacy of any treatment or advice provided.

2. Scope of Care: Services rendered are limited to assessment and treatment as agreed at the time of visit. Any elective, experimental, or ancillary services require separate informed consent and may not be covered by this Disclaimer.

3. Telehealth and Remote Communication: If services are provided remotely, Patient acknowledges that telehealth may present limitations including technology failure, incomplete assessment, or privacy concerns. Provider will take commercially reasonable steps to protect confidentiality, but risk of unauthorized access cannot be eliminated.

4. Emergency Situations: This Disclaimer is not a substitute for emergency medical care. If Patient is experiencing a medical emergency, Patient will contact emergency services or present to an emergency facility immediately.

5. Financial Responsibility: Patient is responsible for payment of charges for services rendered whether or not covered by insurance. Any estimates provided are not guarantees of payment by third-party payors.

6. Release and Limitation of Liability: To the fullest extent permitted by law, Patient releases Provider from liability for ordinary negligence arising from the limitations described above. This release is not intended to and does not waive claims for gross negligence or willful misconduct where prohibited by law.

Acknowledgments, Authorizations, and Consents

I acknowledge that I have read and understand the No Guarantee clause and the Scope of Care described above.

I accept financial responsibility for services rendered and understand that I may be billed for services not covered by my insurer.

If services are provided by telehealth, I acknowledge and accept the limitations and risks associated with remote care.

I authorize Provider to release medical information to my insurer and other healthcare providers as necessary for treatment, payment, and coordination of care.

I acknowledge receipt of the Provider's privacy practices and understand how my health information may be used and disclosed as described in those practices.

By signing below, I certify that the information I have provided is accurate to the best of my knowledge, that I have read and understand this Healthcare Disclaimer in full, and that I accept the limitations, acknowledgments, and authorizations contained herein.

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