Healthcare Med Supp Contract

HEALTHCARE MEDICAL SUPPLEMENT CONTRACT

Parties and Effective Date

Patient Name:   Date of Birth:

Provider Name:   Provider Contact:

Effective Date:

Contract Recitals

This Medical Supplement Contract (the "Contract") sets forth the terms under which Provider will furnish supplemental medical services, supplies, or coordination services that are not ordinarily covered in full by Patient's primary insurance. The parties agree that Patient engages Provider and Provider accepts engagement subject to the terms below.

Patient Information

Insurance Information

Scope of Supplemental Services

Provider will provide the supplemental services described below as part of this Contract. Such services may include, but are not limited to: additional diagnostic services, supplemental durable medical equipment, coordination of benefit activities, out-of-network care coordination, and non-covered therapeutic services. Specific services to be provided and any material limitations are set out here:

Fees, Billing, and Payment

Patient acknowledges responsibility for all fees for supplemental services rendered under this Contract that are not paid by Patient's insurance. Provider will bill insurance when authorized; however Patient remains ultimately responsible for payment of unpaid portions, deductibles, co-payments, co-insurance, and non-covered services.

Patient agrees that unpaid balances may be referred for collection and Patient will be responsible for reasonable collection costs and attorneys' fees. Provider may assign accounts receivable to third parties consistent with applicable law.

Medical History and Current Health Status

Consent, Risks, and Acknowledgments

Patient expressly consents to receive the supplemental services described above, acknowledges that such services may involve risks, and understands alternative treatment options. Patient has had the opportunity to ask questions and has received adequate answers. Patient understands Provider does not guarantee insurance payment and Patient remains financially responsible for charges not paid by insurance.

HIPAA Authorization and Release of Records

By signing below, Patient authorizes Provider to obtain, use, and disclose relevant medical information to third-party payors, other treating providers, and contractors for purposes of billing, claims processing, care coordination, and utilization review. This authorization includes release of medical records and demographic information necessary to coordinate benefits and to facilitate payment for supplemental services.

Patient may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on this authorization. Revocation does not affect disclosures already made in reliance on the authorization prior to revocation.

Limitations of Liability; Indemnification

Except as expressly provided by law, Provider's liability for negligence or breach arising out of performance under this Contract is limited to direct damages and shall not include consequential, incidental, punitive, or special damages. Patient agrees to indemnify and hold Provider harmless from claims arising from Patient's failure to provide accurate information or comply with agreed treatment plans, except where such claims arise from Provider's gross negligence or willful misconduct.

Termination

Either party may terminate this Contract for convenience upon written notice. Provider may suspend services for nonpayment. Termination does not relieve Patient of responsibility for services rendered or for any amounts due for services performed prior to termination.

Dispute Resolution and Governing Law

Any disputes arising out of or relating to this Contract shall first be addressed through good faith negotiation. If unresolved, disputes shall be resolved through binding arbitration under commercial arbitration rules, with the arbitrator's award final and binding. This Contract is governed by the laws of the state governing Provider's principal place of business, without regard to conflict of law rules.

Miscellaneous

This Contract constitutes the entire agreement between Patient and Provider with respect to supplemental services and supersedes prior oral or written representations. Any amendment must be in writing and signed by both parties. If any provision is held invalid, the remainder shall remain in full force and effect.

By checking the box and signing below, Patient certifies that the information provided in this Contract is accurate and complete to the best of Patient's knowledge, authorizes Provider to bill insurance as indicated, and consents to receive supplemental services under the terms described.

I consent to the terms and authorize Provider to obtain/release records for coordination of benefits and billing.

Acknowledgment

Patient acknowledges receipt of a copy of this Contract and understands the financial and privacy terms contained herein.

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