Healthcare Engagement Letter

HEALTHCARE ENGAGEMENT LETTER

This Healthcare Engagement Letter ("Agreement") is made between Provider Name: and Patient Name: .

Effective Date: . This Agreement sets forth the terms under which Provider will deliver professional healthcare services to Patient and the mutual responsibilities of the parties.

Patient Information

Insurance Information

Medical History

Scope of Services

Provider will render professional healthcare services as set forth in the individualized plan of care and consistent with applicable standards of care. Services to be provided include:

The Provider will maintain clinical records and communicate findings to Patient and, when applicable, to Patient's designated representatives. Provider is authorized to consult with other healthcare professionals as reasonably necessary for Patient care.

Fees, Billing, and Payment Responsibility

Patient agrees to pay all fees for services rendered by Provider as described in the Provider's fee schedule. Insurance benefits are accepted as a courtesy and Patient remains ultimately responsible for charges not covered by insurance, including copayments, deductibles, co-insurance, and non-covered services.

By signing this Agreement, Patient authorizes Provider to submit claims to Patient's insurer and to receive insurance payments directly when applicable. Patient authorizes Provider to apply insurance proceeds to outstanding balances for services rendered.

Consent and Authorizations

Patient hereby provides the following consents and acknowledgments (check boxes as applicable):

Confidentiality and HIPAA

Provider will protect the confidentiality of Patient's protected health information in accordance with applicable privacy laws. Patient expressly authorizes Provider to use and disclose health information for treatment, payment, and healthcare operations and understands that such disclosures will be limited to the minimum necessary for the intended purpose.

Termination; Rescheduling and No-Show Policy

Either party may terminate this Agreement upon written notice. Provider may terminate care if Patient fails to abide by agreed treatment plans, fails to pay fees in a timely manner, or engages in abusive behavior toward Provider staff. Provider's cancellation and no-show fee policy will be applied as disclosed to Patient at the time of scheduling.

Dispute Resolution

The parties agree to attempt informal resolution of any disputes arising from this Agreement. If informal resolution is unsuccessful, disputes shall be resolved by binding arbitration under the rules agreed to in a separate arbitration agreement. Nothing in this paragraph shall prevent either party from seeking injunctive relief.

Acknowledgment and Patient Responsibilities

Patient acknowledges that Provider has explained the nature and expected course of care, the patient responsibilities for participation in care, and estimated costs. Patient agrees to disclose relevant medical history and to follow the treatment plan recommended by Provider.

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