Healthcare Health Management Agreement

HEALTH MANAGEMENT AGREEMENT

This Health Management Agreement (the Agreement) is entered into by and between the Provider and the Patient for the purpose of coordinating, managing, and delivering health care services, as set forth below.

Parties

Provider Name:

Patient Name:    Date of Birth:

Scope of Services

Provider will furnish health management services which may include assessment, care planning, coordination of care, referral, medication review, remote monitoring, and follow-up as described in the Service Plan. Services shall be provided in accordance with applicable professional standards.

Anticipated Start Date:    Expected Duration or Review Interval:

Patient Responsibilities and Informed Consent

The Patient agrees to actively participate in the health management plan, attend scheduled appointments or engage by telehealth as agreed, provide accurate medical history, follow prescribed care plans, and communicate changes in condition. The Patient acknowledges that participation is voluntary and that the Patient may withdraw consent at any time as described herein.

I consent to the health management services described above and acknowledge that the Provider has explained the nature of services, anticipated benefits, and foreseeable risks. I understand alternative options and that I may withdraw consent at any time by providing written notice to the Provider.

Consent to Treatment:    I voluntarily consent to the provision of health management services as described.

Insurance, Fees and Billing

I authorize billing of my health insurance and understand that I am responsible for co-payments, deductibles, and any amounts not covered by insurance. Billing Authorization:

Confidentiality and HIPAA Authorization

Provider will protect the confidentiality of protected health information (PHI) in accordance with applicable law and Provider’s privacy policies. The Patient authorizes the Provider to use and disclose PHI as necessary for treatment, payment, and healthcare operations and to communicate with designated contacts.

Authorization to Release PHI:    Expiration of this authorization (if not otherwise specified):

Acknowledgment of Privacy Practices:    I acknowledge receipt of Provider's privacy practices and understand my rights regarding my PHI.

Terms, Termination and Amendment

Term: This Agreement is effective as of the Start Date and shall continue until the Service Plan end date or until terminated by either party. Either party may terminate this Agreement for any reason with written notice to the other party.

Termination Notice Period (days):

Amendments: Any amendment to this Agreement must be in writing and signed by the Patient and an authorized representative of the Provider.

Liability, Indemnification and Dispute Resolution

Provider will perform services in a professional manner consistent with applicable standards. To the extent permitted by law, Provider's liability for claims arising from this Agreement shall be limited to direct damages; Provider disclaims liability for indirect, incidental, or consequential damages. Patient agrees to indemnify Provider for claims arising from Patient's misuse of services or failure to provide accurate information.

Governing Law and Dispute Resolution: This Agreement shall be governed by the laws of the state specified below. Parties agree to attempt resolution in good faith; unresolved disputes may be submitted to mediation or binding arbitration as selected by Provider.

Representations and Warranties

Each party represents and warrants that it has the authority to enter into this Agreement, that the information provided is true and correct to the best of its knowledge, and that performance of this Agreement will not violate other agreements or legal obligations.

Miscellaneous

Entire Agreement: This Agreement, together with the Service Plan, constitutes the entire agreement between the parties with respect to the subject matter and supersedes all prior agreements. Severability: If any provision is held unenforceable, remaining provisions remain in effect.

Authorization and Acknowledgment

The undersigned authorizes the Provider to provide the health management services described herein, to share necessary PHI with designated providers and payors, and certifies that all information provided is accurate. I acknowledge my right to receive a copy of this signed Agreement.

Authorization Expiration (if applicable):

Sign Now