Healthcare Fee Schedule Agreement

HEALTHCARE FEE SCHEDULE AGREEMENT

Parties and Effective Date

Provider Name:

Provider Address:

Patient Name:

Patient Date of Birth:

Effective Date of Agreement:

Recitals

This Healthcare Fee Schedule Agreement (the Agreement) sets forth the current standard fees for professional services, supplies, and ancillary services provided by the Provider to the Patient. The parties intend that the Fee Schedule be the basis for billing and payment for services rendered and that the Patient will be responsible for payment in accordance with the terms below.

Fee Schedule (Itemized)

Instructions:

Enter the service code, brief description, and the standard fee. Fees are stated in U.S. dollars.

Billing, Payment and Insurance

Payment is due at the time of service unless other arrangements are made in advance. Patient shall be responsible for all fees not paid by insurance. Provider may, at its discretion, require partial or full payment prior to providing non-emergency services.

Patient Financial Responsibility

Patient acknowledges responsibility for co-payments, co-insurance, deductibles, and non-covered services. If insurance denies payment in whole or in part, Patient agrees to pay the balance within thirty (30) days of written notice. Patient consents to Provider applying payments from Patient or third parties received against outstanding balances at Provider's standard allocation.

Missed Appointment and Cancellation Fees

Patient agrees that missed appointments or cancellations without at least 24 hours' notice may be subject to a missed appointment fee. The standard missed appointment fee is:

Late Payment, Collections and Interest

Accounts delinquent beyond thirty (30) days may be referred to a collection agency or attorney. Patient acknowledges responsibility for collection costs, court costs, and reasonable attorney's fees if applicable. Interest on unpaid balances will accrue at the lesser of 1.5% per month or the maximum rate permitted by law.

Fee Updates and Notice

Provider may revise the Fee Schedule periodically. Provider will provide written notice of fee changes to the Patient at least thirty (30) days prior to the effective date of the revision. Continued receipt of services after the effective date of a fee change constitutes acceptance of the revised fees by the Patient.

Confidentiality and HIPAA Acknowledgment

Provider maintains a Notice of Privacy Practices describing how medical information may be used and disclosed. By signing this Agreement, Patient acknowledges receipt of that notice and authorizes Provider to use and disclose protected health information for treatment, payment, and healthcare operations in accordance with applicable law.

Termination

Either party may terminate this Agreement for any reason with thirty (30) days' written notice. Termination does not relieve the Patient of financial responsibility for services rendered prior to the effective date of termination.

Dispute Resolution and Governing Law

Any dispute arising under this Agreement that cannot be resolved amicably shall be resolved by binding arbitration in accordance with the rules mutually agreed upon at the time of dispute. This Agreement shall be governed by the substantive laws of the state in which the Provider maintains its primary practice location.

Acknowledgment and Agreement

By signing below, Patient acknowledges that Patient has received, read, and understands the Fee Schedule and the terms set forth in this Agreement; that Patient has had an opportunity to ask questions and have them answered; and that Patient agrees to be financially responsible in accordance with this Agreement.

Additional Authorizations

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