Healthcare Elite Agreement

Healthcare Elite Agreement

This Healthcare Elite Agreement (the Agreement) is entered into by and between Patient Name: and Provider Name: . Effective Date:

Patient Information

Insurance Information

Medical History

Scope of Services, Consent and Authorization

Services to be provided (description): Please describe the nature, purpose and anticipated extent of services to be provided:

Patient acknowledges that the Provider has explained the recommended services, anticipated benefits, material risks, and reasonable alternatives, and that no guarantees have been made regarding results. Patient hereby authorizes Provider and Provider's authorized personnel to perform the services described above and to take such diagnostic and therapeutic measures as are, in Provider's judgment, necessary and appropriate for care.

Assignment of Benefits and Payment Responsibility: Patient agrees to pay Provider for non-covered services, co-payments, co-insurance, deductibles, and any amounts not paid by insurance. Patient assigns to Provider any insurance benefits otherwise payable to Patient for the services rendered. Patient remains responsible for all charges not paid by third-party payors.

Financial Agreement: Initial deposit required: Cancellation / No-Show fee:

Privacy, Release and HIPAA Acknowledgment

I acknowledge that Provider has provided a written Notice of Privacy Practices describing how my protected health information (PHI) may be used and disclosed. I understand my rights with respect to my PHI and I consent to the use and disclosure of my PHI for treatment, payment, and healthcare operations as described in the Notice.

Authorization to Release Medical Information: I authorize Provider to release medical information and records related to treatment to the following individual(s) or entity for the purposes of care coordination and billing:

Patient Representations and Warranties

Patient affirms that the information provided in this Agreement is complete and accurate to the best of Patient's knowledge. Patient will promptly inform Provider in writing of any material changes to medical condition, insurance coverage, or contact information.

Limitation of Liability; Indemnification; Dispute Resolution

To the fullest extent permitted by law, Provider's liability for claims arising out of or related to this Agreement or services performed shall be limited to direct damages and shall not include consequential, incidental, punitive, or special damages. Patient agrees to indemnify and hold Provider harmless from claims arising from Patient's negligent or intentional acts.

Governing Law and Dispute Resolution: This Agreement shall be governed by the laws of the state in which Provider maintains its primary place of business. Any dispute arising under this Agreement shall be resolved by binding arbitration in accordance with commercially reasonable arbitration procedures, unless otherwise required by applicable law.

Termination

Either party may terminate this Agreement upon written notice. Provider may terminate or suspend services immediately if Patient fails to comply with payment obligations or if continued treatment would be harmful to Patient or others.

Acknowledgment and Certification

By signing below, I certify that I have read and understand this Healthcare Elite Agreement, that my questions about the treatment, risks, benefits and alternatives have been answered to my satisfaction, and that I consent to the treatment and billing practices described herein. I understand that I may withdraw this consent in writing at any time, except to the extent that Provider has already taken action in reliance on it.

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