Healthcare Indemnity Form

HEALTHCARE INDEMNITY FORM

This Healthcare Indemnity Form documents the parties, scope, and conditions under which the person receiving services (Patient) agrees to indemnify and hold harmless the healthcare Provider from certain claims, costs, and liabilities arising from the provision of medical care and billing actions as described below. Patient Name: Provider Name: Effective Date:

Patient Information

Emergency Contact

Insurance Information

Medical History (Relevant)

Scope of Services / Description of Indemnified Acts

By signing below, the Patient agrees to indemnify, defend, and hold harmless the Provider, its employees, agents, contractors, and affiliates from and against any and all claims, demands, causes of action, losses, liabilities, damages, fines, penalties, costs and expenses (including reasonable attorneys' fees and costs of investigation) arising out of or in connection with: (a) payment disputes, balance billing, or claims by third-party payors; (b) release of medical records to payors or other authorized persons pursuant to applicable law and patient authorizations; and (c) patient-directed communications that result in third-party claims related to treatment covered herein. This indemnity does not apply to claims resulting from the Provider's gross negligence or willful misconduct.

Patient also acknowledges financial responsibility for charges not paid by insurance and authorizes the Provider to seek payment from Patient for any such unpaid amounts. Patient agrees to reimburse Provider for reasonable collection costs, including attorneys' fees, if collection action is necessary to recover amounts due.

Insurance Assignment and Authorizations

Patient hereby assigns to Provider any and all rights to payment and benefits under any insurance policy, workers' compensation, or third-party recovery related to the services described above, to the extent necessary to satisfy the Provider's billed charges. Patient authorizes Provider to release medical information necessary to process claims and to communicate with payors regarding benefits and payment.

HIPAA & Privacy Acknowledgment

Patient acknowledges receipt of the Provider's Notice of Privacy Practices and consents to the use and disclosure of protected health information for treatment, payment, and healthcare operations as described in that notice. Patient further authorizes the Provider to discuss relevant protected health information with the following individual(s) in case of inquiry or emergency.

Authorization Term and Revocation

This indemnity and all authorizations herein shall remain in effect beginning on the Effective Date above and shall continue until the earlier of: (a) payment in full of Provider's billed charges for the services described herein; (b) expiration on the date specified below; or (c) written revocation delivered to Provider, except that revocation will not affect actions taken in reliance upon this authorization prior to receipt of revocation.

Representations and Certification

Patient represents that all information provided on this form is true, complete, and accurate to the best of Patient's knowledge. Patient understands that knowingly providing false information may constitute grounds for denial of benefits and may expose Patient to civil or criminal liability under applicable law. Patient affirms that they have the authority to execute this indemnity or, if signing as a guardian or legal representative, that they have legal authority to bind the patient.

Acknowledgment

By signing below, Patient acknowledges that Patient has read and understands this Healthcare Indemnity Form, has had the opportunity to ask questions, and agrees to be bound by its terms.

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