Healthcare Internal Medicine Agreement

HEALTHCARE INTERNAL MEDICINE AGREEMENT

This Healthcare Internal Medicine Agreement (the Agreement) is entered into between Practice Name: located at Address: and Patient Name: .

PATIENT INFORMATION

INSURANCE INFORMATION

MEDICAL HISTORY & CURRENT STATUS

SCOPE OF SERVICES

Provider agrees to furnish internal medicine services to patient consistent with accepted standards of care. Services may include evaluation, diagnosis, medical management, ordering and review of diagnostic testing, coordination of care with other providers, and preventive health counseling. The scope of services excludes surgical procedures not ordinarily performed in an internal medicine practice unless separately agreed in writing.

PATIENT RESPONSIBILITIES

The patient agrees to provide accurate medical history and medication information, to follow prescribed treatment plans, to attend scheduled appointments, and to notify the practice promptly of any change in health status. The patient acknowledges responsibility for providing current insurance information and for payment of applicable co-payments, deductibles, and charges not covered by insurance.

FINANCIAL RESPONSIBILITY & ASSIGNMENT OF BENEFITS

The patient authorizes the practice to submit claims to insurance carriers on the patient's behalf and assigns benefits to the practice to the extent permitted by law for services rendered. The patient remains ultimately responsible for all fees for services rendered, whether or not paid by insurance. The patient agrees to pay estimated co-payments or co-insurance at time of service and understands that unpaid balances may be referred for collection consistent with the practice's policies.

CONSENT FOR TREATMENT

I consent to the examination, diagnostic procedures, and medical treatment deemed necessary by the provider and its authorized staff. I understand that no specific promises have been made to me regarding the results of treatment. I acknowledge that all procedures and treatments have potential risks and benefits and that I have the right to ask questions and to withdraw consent at any time, except where withdrawal would expose me to immediate risk.

RISKS, BENEFITS, AND ALTERNATIVES

The practice has explained the nature, expected benefits, and material risks of recommended evaluations and treatments, as well as reasonable alternatives including no treatment. The patient acknowledges the opportunity to ask questions and to receive answers in a manner reasonably understood. The patient further acknowledges that outcomes cannot be guaranteed.

HIPAA PRIVACY AUTHORIZATION & ACKNOWLEDGMENT

By signing below, the patient acknowledges receipt of the practice's Notice of Privacy Practices and authorizes the practice to use and disclose protected health information for treatment, payment, and healthcare operations as described in that notice. The patient authorizes communications by telephone, voicemail, text message, or email at the contact points provided, unless otherwise indicated in writing.

AUTHORIZATION TO RELEASE MEDICAL RECORDS

I authorize the practice to release medical information to other healthcare providers, payors, or persons designated by me as necessary for continuity of care and payment. This authorization shall remain in force until revoked in writing, except to the extent action has already been taken in reliance upon it. This authorization is subject to applicable law governing its scope and duration.

TERMINATION AND AMENDMENT

Either party may terminate the provision of services upon reasonable written notice. The practice may terminate services immediately when necessary for patient safety or for noncompliance with office policies. This Agreement may be amended only by a written instrument signed by both parties.

GOVERNING LAW & DISPUTE RESOLUTION

This Agreement shall be governed by applicable state law. Parties agree to attempt good faith resolution of disputes through informal negotiation. If unresolved, disputes may be subject to mediation or binding arbitration consistent with applicable law, as selected by the practice, except that emergency relief may be sought in a court of competent jurisdiction where necessary.

MISCELLANEOUS

If any provision of this Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force. This Agreement constitutes the entire agreement between the parties regarding the subject matter herein and supersedes prior oral or written statements. Patient confirms that the information provided in this Agreement is accurate to the best of the patient's knowledge.

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