Healthcare Indemnification Form

HEALTHCARE INDEMNIFICATION FORM

Patient Name:    Date of Birth:

Patient Information

Insurance Information (if applicable)

Service / Procedure Information

Reason for Indemnification Request

I request that the Provider proceed with the above-described service despite one or more of the following circumstances (check all that apply):

  Non-covered or elective service not covered by insurer

  Alternative treatment requested in lieu of recommended standard treatment

  Patient declines recommended tests or procedures that are considered standard of care

  Other (explain below)

Indemnification and Hold Harmless Agreement

In consideration of receiving the services described above, Patient Name: (the "Indemnitor") hereby agrees as follows:

1. Indemnification: The Indemnitor shall indemnify, defend and hold harmless Provider, Facility, and their respective officers, directors, employees, agents and contractors (collectively, the "Indemnitees") from and against any and all liabilities, claims, demands, actions, losses, damages, costs and expenses (including reasonable attorneys' fees and costs) arising out of or relating to the Indemnitor's request for or participation in the above-described service, including but not limited to claims resulting from (a) non-covered services, (b) patient-requested alternative treatments, (c) the Indemnitor's failure to follow medical instructions, or (d) complications arising from preexisting conditions disclosed or undisclosed by the Indemnitor, except to the extent caused by the gross negligence or willful misconduct of an Indemnitee.

2. Defense and Notice: The Indemnitor shall promptly notify Indemnitees in writing of any claim for which indemnity may be sought. Indemnitees may elect to assume control of the defense of any such claim; provided, however, that Indemnitees shall not admit liability or settle any claim without the Indemnitor's prior written consent unless required by law. The Indemnitor shall cooperate fully in the defense of any claim.

3. Payments and Collection Costs: The Indemnitor shall pay all amounts due under this Agreement within thirty (30) days of demand. Any amounts not paid when due shall accrue interest at the lesser of 1.5% per month or the maximum rate permitted by law. The Indemnitor agrees to reimburse Indemnitees for reasonable costs of collection, including attorneys' fees.

4. Limitation: This indemnity does not apply to claims arising solely from the gross negligence or willful misconduct of an Indemnitee. This Agreement is intended to allocate risk between the parties and shall be interpreted in a manner that respects applicable law.

5. Cooperation with Coverage Determinations: The Indemnitor acknowledges that the Provider may attempt to obtain payment from the Indemnitor's insurer and that any insurance coverage determination is between the insurer and the Indemnitor. The Indemnitor remains primarily responsible for payment as set forth in this Agreement.

HIPAA Authorization and Privacy Acknowledgment

I authorize the release of any medical information necessary to process claims or otherwise effectuate the indemnity and to defend or prosecute any claim arising from the services described in this form. I acknowledge that my protected health information may be disclosed to the Indemnitees and legal representatives for the limited purpose of claims administration and defense.

This authorization shall remain in effect until: unless earlier revoked in writing. I understand that I may revoke this authorization at any time by providing written notice except to the extent that the information has already been used or disclosed in reliance on this authorization.

Capacity; Guardian or Representative

I represent that I am legally competent to execute this Agreement. If I am signing as a parent, legal guardian, or authorized representative, I affirm that I have the legal authority to bind the Patient and that my relationship to the Patient is indicated below.

  I am the Patient and sign on my own behalf

  I am signing as parent, legal guardian, or authorized representative

Acknowledgment and Certification

By signing below I certify under penalty of law that I have read and understand the terms of this Healthcare Indemnification Form, that all information provided herein is true and complete to the best of my knowledge, and that I voluntarily accept financial responsibility and the indemnification obligations set forth above. I understand that I may withdraw this request prior to the provision of services, subject to any costs incurred by Provider to that date.

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