Healthcare HPHC Agreement

HEALTHCARE HPHC AGREEMENT

Patient Information

Patient Name:     Date of Birth:

Female    Male    Other / Prefer not to say

Insurance Information

Medical History

Scope of Services and Consent

Provider will furnish healthcare services under the Health Plan/Practice HPHC program, including evaluation, diagnostics, treatment planning, and ongoing care as described below. Patient acknowledges and consents to the services described:

By selecting the boxes below, the Patient expressly authorizes the actions described and acknowledges the associated terms, risks, and responsibilities.

I authorize the Provider and authorized clinicians to perform the services described and ancillary care reasonably related to such services.

I authorize assignment of benefits and direct payment to Provider from my insurance for services rendered and understand I remain responsible for non-covered charges, co-payments, and deductibles.

I authorize release of medical information to insurers, referring providers, and other healthcare entities as necessary for treatment, payment, or healthcare operations.

HIPAA Authorization and Privacy

Patient acknowledges receipt of the Provider's Notice of Privacy Practices describing how protected health information may be used and disclosed. Patient authorizes use and disclosure of protected health information for treatment, payment, and healthcare operations consistent with applicable law.

Authorization Expiration Date:    (If left blank, this authorization expires upon termination of this agreement or as permitted by law.)

Communications and Authorizations

I authorize the Provider to leave voicemail messages regarding appointments and care at the telephone number(s) provided.

I consent to receive electronic communications (including email or text) about appointments, treatment, and billing. I understand standard electronic communications may not be encrypted.

Fees, Billing and Financial Responsibility

Patient is responsible for all charges for services not paid by insurance. Provider shall bill insurance as directed by Patient; however, Patient remains ultimately responsible for payment. Provider may use third-party collection and legal remedies for unpaid balances, and Patient agrees to reimburse reasonable collection and attorney fees incurred in collection of unpaid balances.

Liability, Termination, and Governing Law

Provider will exercise reasonable skill and care in providing services. To the fullest extent permitted by law, Provider's liability for claims arising from professional services is limited to direct damages and excludes punitive damages, indirect damages, and lost profits. Either party may terminate this Agreement upon written notice; termination does not waive Patient's obligation to pay for services rendered prior to termination. This Agreement shall be governed by the laws of the state in which Provider maintains its primary practice location.

Acknowledgement and Certification

By signing below, Patient certifies that the information provided is true and accurate to the best of Patient's knowledge; Patient consents to treatment and to the terms set forth in this Healthcare HPHC Agreement; Patient understands the right to withdraw consent in writing except to the extent that action has already been taken in reliance on this Agreement.

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