Healthcare Letter of Intent

HEALTHCARE LETTER OF INTENT

Date:

Patient Name:    Provider / Facility Name:

Patient Information

Male Female Other / Prefer not to say

Emergency Contact

Insurance Information

Medical History (Relevant)

Letter of Intent — Proposed Services and Terms

This Letter of Intent sets forth the patient’s intent to receive the following services from the provider listed above. It is intended to document the parties’ mutual understanding regarding the proposed course of care and the administrative terms that will govern initial treatment pending execution of definitive consent or contract documents.

Proposed Start Date:    Anticipated Duration or Frequency:

Administrative and Legal Terms

Non-binding intent: Except as otherwise expressly provided below, this Letter of Intent is non-binding and is intended only to record the current intentions of the parties. Neither party shall be obligated to provide or accept services until a definitive written consent for treatment or service agreement is executed, except that confidentiality, release authorizations, and certain administrative acknowledgments in this Letter shall be effective upon signature.

Conditions precedent: The obligations described herein are conditioned upon verification of insurance eligibility, completion of required pre-treatment evaluations, and execution of any required informed consent or financial agreement forms. The provider’s obligation to reserve capacity or schedule services under this Letter is contingent on these conditions being satisfied.

Financial responsibility: The patient acknowledges responsibility for any co-payments, deductibles, or non-covered services as set forth in provider policies. Insurance coverage is not guaranteed and final billing will reflect services actually rendered and allowable amounts under the patient’s plan.

Confidentiality and records: The provider will maintain the patient’s medical records in accordance with applicable law. By signing this Letter the patient authorizes the provider to access prior medical records and to exchange information with treating providers, payers, and authorized agents as needed to coordinate care and process claims.

I authorize the provider to obtain prior medical records and to release records related to treatment, billing, and quality review to other health care providers, payers, or their agents as necessary for care coordination and payment.

HIPAA / Privacy Acknowledgment & Authorization

The patient acknowledges receipt of the provider’s Notice of Privacy Practices and understands that protected health information will be used and disclosed in accordance with applicable privacy laws for treatment, payment, and health care operations.

I hereby specifically authorize disclosure of my protected health information for the purposes described in this Letter. Scope of disclosure may include medical history, diagnostic test results, treatment plans, and billing information.

Revocation: The patient may revoke this authorization at any time by written notice to the provider, except to the extent the provider has already acted in reliance on the authorization. Revocation will not affect disclosures made prior to receipt of revocation.

Representations and Certification

By signing below the patient represents and warrants that the information provided in this Letter of Intent is true and accurate to the best of the patient’s knowledge, that the patient has authority to provide the authorizations contained herein, and that the patient understands the non-binding nature of the general terms except where expressly stated otherwise.

Expiration of this Letter: Unless otherwise agreed in writing, this Letter of Intent will expire on .

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