Healthcare Extension Agreement

HEALTHCARE EXTENSION AGREEMENT

This Healthcare Extension Agreement (the "Agreement") is entered into by and between Patient Name: and Healthcare Provider Name: . The parties agree as set forth below to extend the provision of clinical services, care coordination, and related administrative actions as described in this Agreement.

1. Purpose and Recitals

The purpose of this Agreement is to authorize an extension of ongoing healthcare services and associated administrative authorizations beyond the previously agreed term, to permit continuity of care, billing, communication with insurers, and release of medical information necessary to support continued treatment. This Agreement supplements any existing treatment plan or service agreement between Patient Name and Healthcare Provider Name.

2. Patient Information

3. Insurance and Billing

Additional fees, copayments, deductibles, or cost-sharing obligations arising from the extension of services are the responsibility of the patient or the patient's designated payer, unless otherwise agreed in writing. Patient agrees to cooperate with Provider in obtaining billing authorizations and necessary pre-certifications from insurer(s).

4. Extension of Services — Scope

5. Term of Extension

Effective Date:   Expiration Date:   If no expiration date, state termination event:

6. Medical History and Clinical Information

7. Risks, Benefits and Patient Acknowledgment

Patient acknowledges that extending services may present risks and that the expected benefits, reasonable alternatives, and potential complications have been explained. Patient retains the right to withdraw consent for the extension at any time by providing written notice to the Provider subject to any clinically necessary continuity of care obligations.

8. Authorization to Disclose and Obtain Records

Patient authorizes Provider to obtain and disclose medical records, insurance information, and treatment-related information to third parties as reasonably necessary to effectuate the extension of care, obtain payment, or coordinate services. This authorization includes but is not limited to communications with insurers, prior providers, pharmacists, and care coordination entities.

9. HIPAA and Privacy Acknowledgment

By signing below, Patient acknowledges receipt of the Provider's Notice of Privacy Practices and expressly consents to the uses and disclosures described in Section 8 for the limited purpose of extending treatment and obtaining payment for extended services.

I acknowledge receipt of the Provider's Notice of Privacy Practices.

I consent to the disclosure and exchange of my protected health information as necessary to implement this extension.

10. Termination and Revocation

Either party may terminate this Agreement for any reason upon written notice to the other party. Patient may revoke the authorizations in Sections 8 and 9 at any time by written notice, except to the extent that Provider has already relied on the authorization or disclosure to act in the patient's care or billing.

11. Representations, Warranties and Governing Law

Each party represents that it has the authority to enter into this Agreement. This Agreement shall be governed by the laws of the state identified below and any dispute shall be subject to the exclusive jurisdiction of the state and federal courts located within that state unless the parties agree otherwise in writing.

12. Miscellaneous Provisions

This Agreement constitutes the entire agreement with respect to the subject matter herein and supersedes prior oral or written agreements solely to the extent they conflict with this extension. Any amendment must be in writing and signed by both parties. If any provision is held invalid, the remainder shall remain effective.

13. Additional Notes

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