Healthcare Family Clinic Agreement

HEALTHCARE FAMILY CLINIC AGREEMENT

This Healthcare Family Clinic Agreement (the Agreement) is entered into between Clinic Name: and Patient Name: . Effective Date:

1. Patient Information

2. Insurance Information

3. Medical History

4. Consent and Authorization

By checking the box below and signing this Agreement, Patient authorizes the Clinic to provide medically necessary assessment, diagnostic procedures, treatments and ancillary services as determined by Clinic clinical staff. Patient acknowledges that no guarantee has been made as to the results of any treatment.

I consent to examination and treatment by qualified Clinic personnel, including minors where I am the legal guardian and have indicated such on this form.

Patient further authorizes Clinic to obtain, use and disclose protected health information as necessary for treatment, payment, and healthcare operations. This authorization includes communication with other healthcare providers and insurance carriers when necessary for coordination of care.

I authorize the release of medical information to insurers, referred providers, and other entities as required for billing, claims adjudication, and continuity of care.

5. Financial Responsibility

Patient is financially responsible for all charges for services rendered by Clinic that are not covered by insurance or that are denied by an insurer. Patient agrees to provide accurate insurance information and to cooperate with billing and claims procedures. Patient agrees to pay co-payments, co-insurance, deductibles and charges not covered by insurance at the time of service unless other arrangements have been made in writing.

I agree to the financial responsibility terms above and understand that I am responsible for collection costs and reasonable attorney fees for unpaid balances where allowed by law.

6. Appointment, Cancellation and No-Show

Patient agrees to provide timely notice of cancellation. Clinic may charge a fee for missed appointments or cancellations without required notice. Failure to comply with appointment policies may result in discharge from the practice.

I acknowledge the Clinic's appointment cancellation and no-show policy.

7. HIPAA / Privacy Acknowledgment

Patient acknowledges receipt of the Clinic's Notice of Privacy Practices describing how protected health information may be used and disclosed and how Patient can access this information. Patient understands rights regarding privacy and may request restrictions or confidential communications as allowed by law.

I acknowledge that I have received and reviewed the Clinic's Notice of Privacy Practices.

8. Minors and Guardians

If Patient is a minor or otherwise requires a guardian to consent, the person signing on behalf of Patient represents they have legal authority to do so and agree to the terms herein.

Patient is under 18 or requires guardian consent.

9. Termination; Governing Law

Either party may terminate this Agreement upon written notice. Termination does not relieve Patient of obligations for services rendered prior to termination. This Agreement is governed by applicable state law and any dispute resolution shall proceed in the forum designated by Clinic policies subject to mandatory law.

10. Miscellaneous Provisions

Entire Agreement: This Agreement, together with any applicable consent or authorization forms executed contemporaneously, constitutes the entire agreement between the parties concerning the subject matter herein.

Amendments: Any amendment to this Agreement must be in writing and signed by both parties or their authorized representatives.

11. Patient Certifications

By signing below, Patient certifies that the information provided is true and accurate to the best of Patient's knowledge, consents to the terms above, and acknowledges receipt of billing and privacy notices required by law.

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