Healthcare Maintenance Agreement

HEALTHCARE MAINTENANCE AGREEMENT

This Healthcare Maintenance Agreement (Agreement) is made between Provider Name: ("Provider") and Patient Name: ("Patient"). Effective Date:

Patient Information

Insurance Information

Medical History (Relevant)

Scope of Services

Provider shall furnish routine maintenance services as described below, including but not limited to scheduled assessments, minor in-clinic interventions, device checks (where applicable), medication reviews, patient education, and coordination of referrals to specialists when medically required. Detailed description of the maintenance services:

Fees, Billing and Payment

Patient agrees to pay fees for services as set forth below. Provider will bill insurance when authorized; the Patient remains responsible for co-payments, deductibles, non-covered services, and any balance if insurance payment is insufficient or denied.

Patient and Provider Responsibilities

Consent, Risks and Right to Withdraw

Patient consents to routine maintenance procedures and minor interventions necessary to perform the services described herein. Procedures may include physical assessments, device checks, minor wound care, medication adjustments within delegated protocols, and other non-invasive interventions. Patient acknowledges that no outcome can be guaranteed and that all medical interventions involve risks.

I acknowledge that I have been informed of the potential risks and benefits of routine maintenance services, and that I may ask questions and receive answers in language I understand. I understand that I may withdraw this consent at any time by notifying the Provider in writing, without affecting services already rendered or payments due.

Patient acknowledges understanding and consent:

Privacy, Confidentiality, and HIPAA Acknowledgment

Provider will maintain protected health information in accordance with applicable privacy laws. By signing this Agreement, Patient acknowledges receipt of the Provider's Notice of Privacy Practices and authorizes Provider to use and disclose health information for treatment, payment, and healthcare operations as necessary to provide the maintenance services described.

Patient acknowledges receipt of the privacy notice:

Authorization for Billing and Release of Information

Patient authorizes Provider to release medical information and records as reasonably necessary to process claims and obtain payment from insurers and payors. Patient authorizes direct insurance payment to Provider where permitted.

Termination and Modification

This Agreement remains in effect until terminated by either party upon fourteen (14) days' written notice. Provider may modify service procedures and fees upon thirty (30) days' notice to Patient; modifications do not apply retroactively to services already performed. Termination does not relieve Patient of financial obligations accrued prior to the effective date of termination.

Liability, Indemnification and Governing Law

Provider will exercise reasonable care in providing services. To the fullest extent permitted by law, Patient agrees to release and indemnify Provider from claims arising from Patient's failure to follow medical advice or to disclose material health information. This Agreement will be governed by the laws of the state where Patient receives services.

Miscellaneous

Entire Agreement: This Agreement contains the entire understanding between the parties concerning the subject matter and supersedes prior agreements. Severability: If any provision is found invalid, the remaining provisions will remain in effect. Notices required under this Agreement must be in writing.

Acknowledgment

By signing below, Patient affirms that the information provided is true and complete to the best of their knowledge, that they have had the opportunity to ask questions, and that they consent to the terms of this Healthcare Maintenance Agreement.

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