Healthcare Internal Medicine Contract

HEALTHCARE INTERNAL MEDICINE CONTRACT

This Healthcare Internal Medicine Contract ("Agreement") is entered into by and between Provider Name: with practice address: and Patient Name: effective as of:

Patient Information

Insurance Information

Medical History

Scope of Services

Provider shall render internal medicine services including but not limited to evaluation, diagnosis, management of chronic and acute medical conditions, preventive care, routine health maintenance, referrals to specialists, ordering and interpretation of diagnostic tests, and associated follow-up care (collectively, "Services"). Services may be provided in person, by telephone, or via telemedicine where clinically appropriate and as authorized below.

Consent, Authorization and Patient Responsibilities

By signing this Agreement, Patient consents to receive the Services described above and authorizes Provider to perform such diagnostic and therapeutic procedures as are reasonably necessary in the judgment of Provider. Patient acknowledges that no guarantee is made as to the results of care.

Patient authorizes Provider to disclose medical information and to transmit claims and information to Patient's health plan, and assigns to Provider all rights to payment for medical benefits and insurance proceeds related to the Services. Patient understands and agrees that Patient is financially responsible for all charges not covered by insurance, including copayments, deductibles, co-insurance, and services denied by a carrier.

Financial Terms

Patient agrees to pay charges for Services rendered in accordance with Provider's fee schedule. Patient agrees to timely payment of copayments and amounts not reimbursed by insurance. Provider may charge a fee for returned checks, missed appointments, and collection costs including reasonable attorney's fees where applicable.

Appointment Policy

Patient agrees to provide reasonable notice for cancellations and understands that late cancellations or no-shows may be subject to a fee. Appointments that must be rescheduled should be arranged through Provider's scheduling process.

Privacy and HIPAA Acknowledgment

Patient acknowledges receipt of Provider's Notice of Privacy Practices describing how medical information may be used and disclosed and how Patient can obtain access to this information. Patient understands that Protected Health Information will be used for treatment, payment, and healthcare operations as permitted by law.

Authorization Duration and Revocation

This authorization for release of information, billing, and assignment of benefits shall remain in effect until: , unless earlier revoked in writing by Patient. Revocation will not affect disclosures made in reliance upon the authorization prior to Provider's receipt of the revocation.

Risk, Liability and Dispute Resolution

Patient acknowledges that all medical treatment involves inherent risks. Provider's liability for claims arising under this Agreement shall be limited to direct damages and shall exclude consequential, special, or punitive damages to the extent permitted by law. This limitation shall not apply to acts of gross negligence or willful misconduct.

The parties agree to attempt good faith negotiation of disputes. If negotiation fails, the parties agree to submit the dispute to mediation, and if unresolved, to binding arbitration under the rules agreed by the parties. Judgment on any arbitration award may be entered in any court of competent jurisdiction.

Miscellaneous

This Agreement constitutes the entire understanding between Provider and Patient regarding the subject matter hereof and supersedes prior agreements. Amendments must be in writing and signed by both parties. If any provision is held invalid, the remainder shall remain in full force and effect.

Acknowledgment and Certification

I certify that the information provided on this form is true and correct to the best of my knowledge. I have read and understand this Agreement and voluntarily consent to the provision of Services and the use and release of my medical information as set forth above.

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