Healthcare Health Contract

HEALTHCARE HEALTH CONTRACT

This Healthcare Health Contract (the Agreement) is entered into by and between the healthcare provider and the patient identified below. Provider Name: Provider Address:

Effective Date and Parties

Effective Date:

Patient Information

Male Female Other Prefer not to say

Emergency Contact

Insurance Information

Medical History

Scope of Services and Treatment

Provider agrees to furnish healthcare services as set forth in the treatment plan and any attachments hereto. Services to be provided (describe primary services, limitations, frequency):

Risks and Benefits: The patient acknowledges that no medical treatment is without risk. Provider has explained the reasonably foreseeable risks, benefits, and alternatives associated with the recommended care. Patient initial to acknowledge receipt of risk/benefit information:

Payment, Billing, and Insurance Assignment

Patient agrees to pay all charges for services rendered according to Provider's fee schedule. Insurance will be billed as a courtesy when information is provided. Patient is responsible for any deductible, co-insurance, co-payments, non-covered services, and any balances not paid by insurance.

I authorize Provider to submit claims and receive payment directly from my insurer.

Cancellation / No-Show Policy: Patient agrees to provide at least 24 hours' notice for cancellations. Repeated missed appointments may result in discharge from care and associated charges.

HIPAA Acknowledgment and Authorization

Patient acknowledges receipt of Provider's Notice of Privacy Practices and understands the uses and disclosures of protected health information described therein. Patient authorizes disclosure of PHI to the following persons (if any):

Patient acknowledges that this authorization is voluntary and may be revoked in writing at any time except to the extent that action has been taken in reliance on it.

Authorization to Release Medical Records

Patient authorizes Provider to release medical records as necessary for treatment, payment, or healthcare operations, or as directed below. This authorization expires on:

Termination, Amendment, Liability

Either party may terminate this Agreement upon written notice. Provider may terminate care if patient fails to comply with treatment or payment policies. Provider's liability for any claim arising out of services rendered is limited to direct damages and shall not include consequential or punitive damages to the fullest extent permitted by law.

Dispute Resolution: The parties agree to attempt good faith negotiation of disputes. If unresolved, disputes shall be resolved through binding arbitration under the applicable rules agreed by the parties, and judgment upon the award rendered by the arbitrator(s) may be entered in any court having jurisdiction.

Patient Responsibilities

Patient agrees to: provide accurate medical history; follow prescribed treatment plans; notify Provider of changes to insurance or contact information; pay charges when due. Patient acknowledges the obligation to inform Provider of any advance directives or designated decision-maker.

Patient confirms the information provided on this form is true and complete to the best of their knowledge. Patient acknowledges the right to withdraw consent to treatment at any time, subject to medical necessity and safety requirements.

By signing below, the patient authorizes treatment, acknowledges understanding of risks and benefits, agrees to the terms of billing, and consents to release and use of PHI as set forth above.

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