Healthcare Health Check Contract

HEALTHCARE HEALTH CHECK CONTRACT

This Healthcare Health Check Contract (the Contract) is made between Provider Name: and Patient Name: . Effective Date:

1. Scope of Services

Provider will perform a health check program consisting of history review, physical examination, vital signs, basic laboratory testing as agreed, risk assessment, and counseling (Services). The specific Services to be provided at each visit will be listed in the visit record and may include immunizations, blood tests, urinalysis, and screening questionnaires. Provider will exercise clinical judgment in determining which screening tests are appropriate for Patient.

2. Appointment, Duration & Location

Appointments will be scheduled at Provider's facility located at:

Typical health check visits are expected to last approximately unless additional diagnostic testing is required.

3. Fees, Billing and Insurance

Patient agrees to pay Provider's fees for Services. Provider will bill insurance as a courtesy when valid insurance information is provided. Patient remains financially responsible for all charges not covered by insurance, including co-payments, deductibles, and non-covered services.

4. Patient Information

5. Medical History / Current Health Information

6. Consent to Examination, Tests and Specimen Handling

Patient acknowledges that the Services may include blood draws, urinalysis, and other specimen collection. Patient consents to such examinations and tests and authorizes Provider to collect, process, and temporarily store specimens for diagnostic testing. Provider will handle specimens in accordance with applicable standards. Patient understands that tests may carry risks such as infection at the puncture site or bruising.

Patient has the right to ask questions, decline any specific test, and withdraw consent at any time prior to the procedure without penalty, except as provided below for already-initiated laboratory submissions.

7. HIPAA / Privacy Acknowledgment

Provider maintains a Notice of Privacy Practices describing how medical information may be used and disclosed. By signing this Contract, Patient acknowledges receipt of such notice and agrees that Provider may use and disclose protected health information for treatment, payment, and healthcare operations as permitted by law.

8. Authorization to Release Health Information

Patient authorizes Provider to release health information related to the Services to the following person(s) or entity(ies):

This authorization will expire on: unless revoked earlier in writing by Patient.

9. Cancellation and No-Show Policy

Patient agrees to provide at least 24 hours' notice to cancel or reschedule an appointment. Provider may assess a cancellation or no-show fee to cover administrative costs and lost clinical time. Repeated no-shows may result in termination of scheduling privileges.

10. Liability, Indemnification and Limitation

Provider will exercise reasonable skill and care in providing Services. Patient acknowledges that medical results cannot be guaranteed. To the maximum extent permitted by applicable law, Patient agrees that Provider's liability for any claim arising out of or related to this Contract is limited to direct damages not to exceed the total fees paid by Patient to Provider for the specific Service occasioning the claim. Neither party shall be liable for consequential, incidental, punitive, or special damages. Patient agrees to indemnify and hold Provider harmless from claims arising from Patient's failure to disclose material information or follow Provider's instructions.

11. Termination

Either party may terminate this Contract for any reason upon written notice. Termination does not relieve Patient of responsibility for charges incurred prior to termination. Provider retains the right to discontinue Services for disruptive behavior or nonpayment in accordance with applicable law.

12. Governing Law and Dispute Resolution

This Contract shall be governed by the laws of the jurisdiction in which Provider's primary office is located, without regard to conflict of laws principles. Parties agree to attempt good faith negotiation to resolve disputes. If negotiation fails, disputes shall be resolved by binding arbitration administered in the same jurisdiction, unless otherwise required by law.

13. Miscellaneous

This Contract constitutes the entire agreement between the parties with respect to the subject matter and supersedes all prior agreements. Any amendment must be in writing and signed by both parties. If any provision is held invalid, the remainder will continue in full force and effect.

Acknowledgment and Patient Certification

By signing below, Patient certifies that the information provided in this Contract is true and complete to the best of Patient's knowledge, that Patient has had the opportunity to ask questions about the Services, and that Patient consents to the Services and terms described in this Contract.

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