Healthcare GSA Template

HEALTHCARE GSA TEMPLATE

This Healthcare General Services Agreement and Patient Authorization (the Agreement) documents the terms under which the Provider will furnish health-related goods and services to the Patient and the Patient's authorization for use and disclosure of protected health information as required for administration and treatment.

Patient Name:   Provider Name:

Patient Information

Female    Male    Non-binary    Decline to state

Insurance Information

Medical History

Scope of Services; Fees; Billing

Services to be provided are set forth as follows. The Provider shall render services consistent with applicable standards of care and in accordance with the Patient's treatment plan. Patient authorizes the Provider to deliver the following services:

Fees charged for services will be billed to the insurance identified above and/or to the Patient. The Patient is responsible for copayments, deductibles, coinsurance, and any non-covered services. Provider may suspend non-emergency services for nonpayment in accordance with applicable law.

Insurance & Authorization for Benefits

By signing below the Patient authorizes Provider to submit claims to the insurance carrier and to receive insurance payments on behalf of the Patient, to the extent permissible by law. Patient authorizes release of records necessary to adjudicate claims.

Privacy, HIPAA Authorization, and Use of Protected Health Information (PHI)

Patient acknowledges receipt of Provider's Notice of Privacy Practices and consents to the use and disclosure of PHI for treatment, payment, and healthcare operations as described below. This Authorization is voluntary but necessary for certain billing and administrative activities.

The Patient understands that the information disclosed pursuant to this Authorization may include records relating to behavioral health, communicable disease, substance use disorder, or other sensitive information as necessary. Provider will not condition treatment on signing this Authorization except where permitted by law for specific activities.

Right to Revoke: Patient may revoke this Authorization at any time by delivering a written revocation to the Provider's compliance officer. Revocation will not affect disclosures already made in reliance upon this Authorization prior to receipt of revocation.

Representations; Indemnification; Termination

Patient represents that the information supplied in this document is true and accurate to the best of Patient's knowledge. Patient agrees to indemnify and hold Provider harmless from claims arising from incorrect patient-supplied information or fraudulent insurance claims. Either party may terminate this Agreement upon written notice; termination will not affect rights and obligations accrued prior to termination.

Acknowledgments and Consents

By checking the boxes below and signing, Patient acknowledges and consents to the following:

I consent to receive the described treatment and related services.
I authorize Provider to bill my insurance and accept assignment of benefits when applicable.
I authorize use and disclosure of my PHI as described in this Authorization.
I acknowledge receipt of the Provider's Notice of Privacy Practices.

Limitations; Governing Terms

This Agreement sets forth the entire understanding between Patient and Provider regarding the subject matter hereof and supersedes prior oral or written statements. Any amendment must be in writing and signed by Patient and an authorized representative of Provider. Provider will comply with applicable law in the use, disclosure, and protection of PHI.

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