Healthcare Limited Offer Form

HEALTHCARE LIMITED OFFER FORM

Provider Name:    Offer ID:

Offer Summary

Description of limited offer and included services:

Approximate retail value of included services: $    Limit per patient:

Offer Effective Date:    Offer Expiration Date:

Patient Information

Gender: Male Female Other    If other, specify:

Insurance Information

Medical History

Are you pregnant or suspect you may be?   Yes No

Terms, Conditions, Acknowledgments and Consent

Scope of Offer: The limited offer described above applies only to the specific services listed in the Description of limited offer and only for the individual patient named herein. Services not expressly listed are excluded. Patient acknowledges that the limited offer is non-transferable and may be subject to availability.

Financial Responsibility: Patient understands and agrees that any services, diagnostic testing, or care rendered that are not covered by this limited offer, or that extend beyond the expiration date, may be billed at standard provider rates. Patient authorizes the provider to bill the insurance identified above and/or to collect payment directly from the patient for any covered or uncovered services as permitted by law.

Risks and Benefits: Patient acknowledges that the provider has provided verbal or written information concerning the nature, expected benefits, and potential risks of services provided under this offer. Patient has had the opportunity to ask questions and understands that no guarantee of outcome is made.

Withdrawal and Cancellation: Patient may withdraw acceptance of this limited offer at any time by giving written notice to the provider. Withdrawal will not affect actions taken by the provider prior to receipt of such notice. Provider reserves the right to cancel the offer for any reason, including but not limited to clinical contraindications or regulatory compliance concerns.

I accept the terms of the limited offer described above and authorize the provider to proceed with the included services.

Privacy, Authorization and HIPAA Acknowledgment

Authorization to Use and Disclose Protected Health Information (PHI): By signing below, patient authorizes the provider to use and disclose PHI as reasonably necessary to administer this limited offer, to bill and collect payment, and to arrange for any follow-up care related to services delivered under this offer. This authorization includes disclosure to billing agents, insurance carriers, and other health care providers as necessary for the limited purpose described.

Patient acknowledges receipt of the provider's Notice of Privacy Practices and understands their rights to inspect and receive a copy of PHI, to request restrictions, and to revoke this authorization in writing except to the extent actions have already been taken in reliance on it.

Authorization Expiration: Unless otherwise revoked earlier in writing, this authorization expires on:

By initialing below, patient specifically consents to electronic or telephonic communications related to scheduling, reminders, and limited offer notifications:

Initials:

Limitations and Liability

Release: To the extent permitted by law, patient releases and holds harmless the provider, its employees, agents, and contractors from claims arising solely from the limited nature of this offer, except for willful misconduct or gross negligence. Nothing in this form limits patient rights under applicable consumer protection or health care laws.

Certification

I certify under penalty of perjury that the information provided in this Healthcare Limited Offer Form is true and complete to the best of my knowledge. I acknowledge that I have read and understand the terms, conditions, and limitations of the limited offer, including financial responsibilities and the authorization for use and disclosure of PHI set forth above.

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