Healthcare Evaluation Agreement

HEALTHCARE EVALUATION AGREEMENT

Parties and Identification

Provider Name:

Clinic/Practice Address:

Patient Information

Patient Name:

Date of Birth:    Gender: Male Female Other Prefer not to say

Insurance and Billing

Medical History and Current Status

Scope of Evaluation and Services

This Agreement authorizes Provider to perform a healthcare evaluation of the Patient for the purpose of diagnosis, treatment planning, third-party reporting, eligibility assessment, or other stated clinical objectives. The evaluation may include clinical interview, review of medical and educational records, standardized testing, behavioral observation, and consultation with other treating professionals. Evaluation Date:

The scope, instruments, and estimated duration of testing or assessment will be described verbally and in writing as appropriate. Provider will make reasonable accommodations for communication and access needs. If additional services beyond the agreed evaluation are recommended, those services will require separate consent.

Risks, Benefits, and Alternatives

I understand that possible benefits include improved diagnostic clarity and treatment planning. Potential risks include temporary emotional distress, disclosure of previously unknown information, or incidental findings that may require referral. Reasonable alternatives to the proposed evaluation include deferral, referral to another qualified evaluator, or no evaluation. I have had the opportunity to ask questions about risks, benefits, and alternatives.

Confidentiality and Limits

Information obtained during the evaluation is confidential and will not be disclosed except as permitted by law or with written authorization. Limits to confidentiality include: (1) suspected abuse or neglect of minors, dependent adults, or elders; (2) imminent risk of serious harm to self or others; (3) court order or lawful subpoena; (4) mandated public health reporting; and (5) necessary disclosures to billing entities or payers. Provider will make reasonable efforts to notify Patient prior to disclosure when legally permitted.

Use of Records and Authorization for Release

By signing below, Patient authorizes Provider to obtain and review relevant records from other healthcare, educational, or legal sources as necessary for a complete evaluation. Patient authorizes release of evaluation findings and relevant records to payers for billing and to other identified providers for continuity of care, as indicated on a separate authorization. Authorization Expiration Date:

Fees, Payment, and Insurance

Fees for the evaluation will be communicated prior to testing. Patient is responsible for applicable co-payments, deductibles, and charges not covered by insurance. Submission of claims to insurance does not relieve Patient of responsibility for unpaid balances. Provider may disclose the minimum necessary information to insurers for claims processing. If insurance denies payment, Patient remains responsible for fees incurred.

Cancellation, No-Show, and Rescheduling

Scheduled evaluation appointments require advance notice for cancellation. Provider may assess a cancellation or no-show fee if Patient fails to provide notice within the timeframe described at intake. Repeated cancellations or failure to attend may result in termination of services.

Voluntary Consent and Right to Withdraw

Consent to this evaluation is voluntary. Patient may revoke this consent at any time by providing written notice; however, revocation will not affect disclosures made prior to receipt of revocation nor any actions taken in reasonable reliance on this consent. Withdrawal of consent may limit Provider's ability to complete a full evaluation.

HIPAA / Privacy Acknowledgment

Patient acknowledges receipt of Provider's privacy practices describing how protected health information may be used and disclosed and Patient's privacy rights under applicable law. Patient authorizes Provider to use and disclose health information for treatment, payment, and healthcare operations as described in those practices.

I have read and understand this Healthcare Evaluation Agreement. I have had the opportunity to ask questions and receive satisfactory answers. I consent to the evaluation described and authorize disclosures as necessary for care coordination and billing as stated above.

Consent to audio recording for clinical purposes
Consent to video recording for clinical purposes

Acknowledgment

By signing below, I certify that the information I have provided is complete and accurate to the best of my knowledge; I authorize the evaluation and related disclosures described herein; and I understand my rights and responsibilities under this Agreement.

Sign Now