Healthcare LOO Agreement

HEALTHCARE LOO AGREEMENT

Parties and Purpose

Provider Name:    Provider Address:

Client Name:    Date of Offer:

Purpose: This Letter of Offer ("LOO") sets forth the terms under which the Provider agrees to provide the medical services described below to the Patient and under which the Patient accepts financial responsibility in accordance with the terms of this Agreement.

Patient Information

Male    Female    Other / Prefer not to say

Insurance Information

Medical History (Brief)

Proposed Service and Financial Offer

Procedure / Service:

Scheduled date:    Estimated total charges: $

Required deposit: $    Deposit due by:

Patient acknowledges responsibility for charges not covered by insurance and for any co-payments, co-insurance, deductibles, and non-covered services. Provider will bill the insurance as a courtesy where authorized; however, the Patient remains primarily liable for payment.

Bill insurance on my behalf: Yes

Risks, Benefits and Alternatives

Provider has explained the nature and purpose of the proposed procedure, the significant risks and probable benefits, and reasonable alternatives, including the risks and benefits of not receiving treatment. Patient affirms understanding and consents to proceed under the terms set forth in this LOO.

Patient acknowledges receipt of the above summary and has had an opportunity to ask questions and receive answers to their satisfaction.

HIPAA Authorization and Privacy Acknowledgment

By signing this LOO, Patient acknowledges receipt of Provider's Notice of Privacy Practices and authorizes Provider to use and disclose Protected Health Information (PHI) as necessary for treatment, payment, and healthcare operations, including communication with insurance carriers and other healthcare providers.

Authorization to release records to payers or designated third parties: Yes

Terms, Withdrawal and Miscellaneous Provisions

Withdrawal: Patient retains the right to withdraw consent prior to the commencement of services by notifying Provider in writing. Withdrawal does not relieve Patient of financial responsibility for services already rendered or for non-refundable deposits.

Cancellation and No-Show: Provider's cancellation policy applies. Fees may be assessed for late cancellations and no-shows as set by Provider policy, and Patient agrees to be responsible for such fees.

Governing Law and Dispute Resolution: This Agreement shall be governed by the laws applicable to the Provider's principal place of business. Disputes arising from this Agreement shall be resolved through the dispute resolution process described by Provider, which may include mediation or arbitration as elected by Provider.

Assignment; Third Parties: Patient may not assign this Agreement without Provider's prior written consent. Provider may assign billing rights to third-party billing agents or collection entities.

Entire Agreement: This LOO constitutes the entire agreement between the parties with respect to the services described and supersedes all prior oral or written communications relating to the subject matter herein.

Acknowledgements

By signing below, Patient confirms that the information provided in this LOO is accurate to the best of their knowledge, that they have had an opportunity to ask questions, and that they accept the financial and clinical terms set forth above.

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