Healthcare Individuals Contract

HEALTHCARE INDIVIDUALS CONTRACT

This Healthcare Individuals Contract (the Agreement) is made between Patient Name: and Provider Name: . Effective Date: .

1. Patient Information

2. Emergency Contact

3. Insurance Information

4. Medical History & Current Condition

5. Scope of Services

Provider agrees to provide the professional healthcare services described as follows: Services will be provided consistent with accepted standards of care for the condition(s) identified above and within the provider's scope of practice.

6. Risks, Benefits and Consent

The Patient acknowledges that the proposed treatment has risks and potential complications which have been explained to the Patient, including but not limited to those described in the consent discussion. Benefits and reasonable alternatives have also been explained. The Patient retains the right to withdraw consent at any time prior to or during treatment, subject to clinical judgment concerning safety and continuity of care.

I hereby authorize Provider and its authorized personnel to provide medical treatment, diagnostics and related services as reasonably necessary for care. I authorize emergency treatment should an emergent condition arise during the course of care and agree that reasonable efforts will be made to contact my emergency contact.

Consent to Treatment: I acknowledge and consent.

7. Financial Terms and Assignment of Benefits

The Patient is responsible for all charges for services rendered by Provider that are not paid by insurance, including co-payments, deductibles, co-insurance and services not covered by insurance. Patient agrees to promptly pay Provider for balances due under Provider's standard billing practices.

Assignment of Benefits: Patient assigns benefits payable from insurer to Provider to the extent necessary to reimburse Provider for services rendered. Patient authorizes Provider to submit claims, obtain payment and disclose PHI for claim adjudication and payment.

8. Medical Records, Privacy and HIPAA Authorization

The Patient acknowledges receipt of Provider's privacy practices and consents to the use and disclosure of protected health information (PHI) for treatment, payment and healthcare operations as necessary. Patient further authorizes Provider to disclose PHI to insurers, billing agents and as required by law.

Authorization to Release Records for Billing and Continuity of Care: I authorize release of my medical information for the purposes described.

9. Confidentiality and Use of Information

Provider will maintain the confidentiality of Patient records in accordance with applicable law. Patient consents to Provider's use of de-identified data for quality improvement, training and internal operations provided that identity is not disclosed.

10. Limitation of Liability and Indemnification

Provider's liability for any claim arising under this Agreement is limited to actual direct damages and in no event shall Provider be liable for consequential, incidental, special or punitive damages. Patient agrees to indemnify and hold Provider harmless from any claims arising out of Patient's failure to disclose material medical information or to follow medical advice given by Provider.

11. Termination

Either party may terminate this Agreement for any reason upon written notice to the other party. Provider may withhold further treatment when permitted by law and after giving reasonable notice and referral resources where practicable.

12. Dispute Resolution and Governing Law

Any dispute arising out of this Agreement shall be governed by the laws of the jurisdiction where Provider practices, without regard to conflict-of-law principles. Parties agree to attempt good faith negotiation prior to initiating litigation. Where permitted, Provider may require mediation or arbitration for resolution of disputes.

13. Miscellaneous

This Agreement constitutes the entire agreement between the parties concerning the subject matter herein and supersedes prior discussions. No amendment is effective unless in writing and signed by both parties. If any provision is found unenforceable, the remaining provisions remain in full force.

14. Acknowledgment and Certification

By signing below, the Patient certifies that the information provided is true and complete to the best of Patient's knowledge, that Patient has had the opportunity to ask questions, and that Patient consents to the treatment, billing and information practices set forth above.

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