Healthcare Locums Document

Healthcare Locums Assignment and Provider Agreement

Parties and Effective Date

This Agreement is entered into between Facility Name: ("Facility") and Locum Provider Name: ("Provider"). Effective Date:

Provider Identification and Credentials

Assignment Details

Assignment Site: Start Date: End Date (anticipated):

Patient Assignment Record (for Locum use)

Use this section to record patient details during Assignment shifts.

Date of Birth: Gender: Phone:

Insurance and Medical History (patient)

Provider Insurance, Background & Compliance

Provider attests that background checks, drug screens, and credential verification have been completed and are current: Completed Immunizations on file

Compensation, Billing and Expenses

Standards of Care; Confidentiality; HIPAA

Provider shall perform services in accordance with applicable professional standards, Facility policies, and all federal and state laws. Provider shall maintain patient records, document all encounters contemporaneously, and deliver documentation to Facility as required. Provider shall not disclose protected health information except as required for treatment, payment, or healthcare operations or as otherwise permitted by law.

Provider affirms compliance with HIPAA and related privacy and security rules. Provider understands breach notification obligations and shall notify Facility promptly of any unauthorized disclosure involving Facility patients.

Indemnification; Termination

Each party shall indemnify, defend, and hold the other harmless from claims arising from its own negligent acts or omissions. Facility may terminate the Assignment for cause upon written notice or immediately for licensure suspension, loss of malpractice coverage, or conduct jeopardizing patient safety. Provider may terminate with reasonable notice as set forth in this Agreement.

Representations and Certifications

Provider represents and certifies that all information provided to Facility is true and complete; Provider holds an unrestricted license to practice in stated jurisdictions; no disciplinary actions or criminal convictions exist that would materially affect performance. Provider consents to verification of credentials and background checks as needed.

Acknowledgement

By signing below, the parties acknowledge they have authority to execute this Agreement, have received and reviewed the included patient information fields where applicable, and agree to the terms set forth herein.

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