Healthcare Home Contract

HEALTHCARE HOME CONTRACT

Parties and Effective Date

This Healthcare Home Contract is entered into between Home Health Agency: located at and Patient Name: .

Effective Date:

Patient Information

Emergency Contact

Insurance and Billing

Insurance Billing Authorization: I authorize the Home Health Agency to bill insurance and to receive payment directly.

Medical History and Current Condition

Scope of Services and Care Plan

The Agency agrees to provide home health services as ordered by the attending physician. Services may include skilled nursing, physical therapy, occupational therapy, speech therapy, and personal care as documented in the individualized care plan. Services to be provided:

Frequency and duration of visits: Start Date: Anticipated End Date:

Payment, Rates and Billing

The Client agrees to pay for services as follows. Insurance will be billed where applicable; any co-payments, deductibles or non-covered services are the responsibility of the Client.

Late payment or non-payment may result in suspension of non-emergency services after written notice. Client is responsible for costs of collection, including reasonable attorney fees where permitted by law.

Patient Rights, Responsibilities and Consent

Patient Rights: Patient has the right to be informed, to participate in care planning, to refuse services, and to receive care in a safe environment. Patient Responsibilities: to provide accurate information, to follow agreed care plan, to notify Agency of changes, and to pay applicable charges.

By checking the box below, the Patient acknowledges receipt of these rights and responsibilities and consents to services as described in this Contract.

Patient consents to the provision of home health services described in this Contract.

Confidentiality and HIPAA

The Agency will maintain the confidentiality of patient health information and use or disclose such information only as necessary to provide treatment, to obtain payment, or as required by law. The Patient acknowledges receipt of the Agency's privacy practices.

I acknowledge receipt of the Agency's Notice of Privacy Practices and authorize use and disclosure of protected health information for treatment, payment, and health care operations.

Termination and Right to Withdraw

Either party may terminate this Contract with written notice. The Agency may terminate immediately where continued services would pose a risk to staff or patient, or where the patient fails to comply with the plan of care. Termination does not relieve the Patient from payment of services rendered prior to termination.

Liability, Indemnity and Limitation of Remedies

The Agency shall exercise reasonable care in providing services. The Agency is not liable for acts or omissions caused by third parties, unforeseeable events, or the Patient's failure to follow medical advice. To the maximum extent permitted by law, neither party shall be liable to the other for consequential or punitive damages. The Patient agrees to indemnify the Agency for claims arising from Patient's breach of this Contract.

Authorization and Release

The Patient authorizes the Agency to obtain medical information from treating providers and to share necessary information with payers for billing and care coordination. The Patient authorizes the Agency to photograph or document clinical conditions for clinical records where applicable.

Notices

Any notice under this Contract shall be in writing and delivered to the contact information listed below. Notices are effective upon personal delivery or three (3) days after deposit in the United States mail, postage prepaid.

Dispute Resolution and Governing Law

The parties agree to attempt resolution of disputes through good faith negotiation. If unresolved, disputes shall be subject to mediation and, if necessary, binding arbitration. This Contract is governed by the laws of the state indicated in the Agency's business address.

Acknowledgment

By signing below the parties acknowledge that they have read and understand this Contract, that services authorized herein conform to the attending physician's orders, and that they agree to the terms and conditions stated.

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