Healthcare Engagement Agreement

HEALTHCARE ENGAGEMENT AGREEMENT

This Healthcare Engagement Agreement ("Agreement") is entered into effective as of , by and between Provider Name:

1. Patient Information

2. Emergency Contact

3. Insurance Information

4. Medical History

5. Scope of Services

Provider shall deliver healthcare services as agreed in writing and as reasonably necessary for diagnosis, treatment and care planning. The specific services to be provided are:

Provider may perform services in person, by telehealth, or through authorized delegates. Patient consents to the use of telehealth where clinically appropriate.

6. Financial Terms; Insurance Assignment

Patient agrees to pay all fees for services rendered. Provider will bill applicable insurance carriers when timely and accurate insurance information is provided. Patient remains primarily responsible for any charges not covered by insurance, including co-payments, deductibles, and services denied as not medically necessary.

Assignment of Benefits: Patient hereby assigns to Provider all medical benefits and insurance proceeds payable for services described herein, subject to the following selection:

Patient acknowledges responsibility for payment of any amounts not paid by insurance within sixty (60) days of notice and agrees to reimburse Provider for reasonable collection costs, including attorney fees where permitted by law.

7. Consent to Treatment

Patient voluntarily consents to evaluation, diagnostic procedures and treatment by Provider and Provider's authorized staff. Patient acknowledges that no guarantee of specific results has been promised and that all procedures carry inherent risks.

Patient retains the right to refuse or withdraw consent at any time, except where withdrawal would jeopardize patient safety or violate applicable law.

8. Confidentiality and HIPAA

Provider maintains protected health information in accordance with applicable privacy laws. By signing this Agreement, Patient acknowledges receipt of Provider's Notice of Privacy Practices and understands how health information may be used and disclosed for treatment, payment and healthcare operations.

9. Authorization to Release Medical Records

Patient authorizes Provider to release protected health information to the persons or entities identified below for purposes of payment, continuity of care, or as otherwise permitted by law. This authorization is voluntary and may be revoked in writing, except to the extent Provider has already acted in reliance upon it.

10. Term, Termination and Withdrawal

This Agreement remains in effect until the completion of the Services described herein or until terminated by either party upon written notice. Provider may terminate immediately for nonpayment, material breach, or where continuation would present a risk to patient or staff safety. Termination does not relieve Patient of financial obligations for services rendered prior to termination.

11. Limitation of Liability; Indemnification

Except for willful misconduct or gross negligence, Provider's liability for damages arising from the provision of services is limited to direct damages not to exceed the amount actually paid by Patient to Provider for services at issue. Patient agrees to indemnify and hold Provider harmless from third-party claims arising from Patient's actions or omissions.

12. Dispute Resolution; Governing Law

Any dispute concerning this Agreement or services provided will first be addressed through good-faith negotiation. If unresolved, disputes shall be resolved by binding arbitration in the jurisdiction where Provider maintains its primary practice, in accordance with the rules of the selected arbitration forum. This Agreement is governed by the substantive laws of the governing jurisdiction.

13. Miscellaneous

This Agreement constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes prior oral or written representations. If any provision is held invalid, remaining provisions will remain in full force. Amendments must be in writing and signed by both parties.

Patient certifies that the information provided on this form is true and complete to the best of Patient's knowledge and understands that deliberate falsification may be grounds for denial of services and termination of coverage.

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