Healthcare Level Agreement

HEALTHCARE LEVEL AGREEMENT

This Healthcare Level Agreement (the Agreement) sets forth the mutually binding commitments between the parties regarding the scope, performance, confidentiality, and patient rights in connection with the delivery of healthcare services.

Parties and Effective Date

Patient Name:     Provider Name:

Effective Date:

Scope of Services

The provider agrees to deliver healthcare services at the levels and modalities selected below. Patient selects the applicable levels of care by checking the corresponding boxes. Services provided under this Agreement are subject to clinical appropriateness and applicable law.

Primary Care
Chronic Care Management
Urgent Care Services
Telehealth Services
Home Health / In-Home Visits

Service Levels and Response Times

For each selected level of care, the provider shall meet the following standard response times and availability targets. Patient acknowledges that clinical exigencies may alter response times.

Response for urgent telephone triage:    On-site urgent visit target:

Provider Responsibilities

The provider shall: (a) deliver services in a medically appropriate and timely manner; (b) maintain accurate clinical records; (c) ensure staff compliance with applicable licensing and credentialing; (d) implement reasonable administrative, physical and technical safeguards to protect patient health information; and (e) notify patient of material changes to service levels within a reasonable time.

Patient Responsibilities

The patient shall: (a) provide accurate medical and insurance information; (b) follow care plans and instructions provided by the provider; (c) notify provider of any change in condition or contact information; (d) remit applicable co-payments, deductibles, or fees in accordance with provider billing policies; and (e) follow safety and infection control instructions where applicable.

Privacy, Data Security, and HIPAA Acknowledgment

The provider's privacy practices govern use and disclosure of protected health information. The provider will use reasonable administrative, physical and technical safeguards to protect patient information. Patient has the right to receive a copy of the provider's privacy practices upon request.

I acknowledge receipt of, and agree to the use and disclosure of my health information consistent with the provider's privacy practices and this Agreement:
I acknowledge and consent     Initials:

Consent and Authorization

Patient authorizes the provider to deliver the selected levels of care, to obtain and share health information as necessary for treatment, payment, and healthcare operations, and to communicate by the contact methods provided. Patient retains the right to revoke this authorization in writing, except to the extent the provider has already acted in reliance on the authorization.

Insurance and Billing

Medical History (Summary)

Emergency Contact and Communication Preferences

Phone SMS/Text Email Patient Portal

Termination, Limitation of Liability, and Dispute Resolution

Either party may terminate this Agreement upon written notice to the other party in accordance with the provider's termination policies. Provider's liability for claims arising from services performed under this Agreement shall be limited to direct damages up to an aggregate amount equal to the fees paid by or on behalf of the patient for services rendered in the prior twelve months, to the extent permitted by law. Neither party shall be liable for consequential, incidental, or punitive damages except as required by applicable law.

Disputes arising from this Agreement shall first be addressed through good-faith negotiation. If unresolved, the parties may pursue mediation or other non-binding alternative dispute resolution, and thereafter may pursue any remedies available at law or equity in the courts of competent jurisdiction.

Acknowledgment and Certification

By signing below, I certify that the information provided is accurate and complete to the best of my knowledge; I consent to receive the selected services; I acknowledge my responsibilities under this Agreement; and I understand my rights regarding privacy and revocation of authorization.

I further acknowledge that I have had the opportunity to ask questions and that my questions were answered to my satisfaction.

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