Healthcare Medica Contract

HEALTHCARE MEDICA CONTRACT

This Healthcare Medica Contract (the "Agreement") is entered into by and between Provider Name: with principal address: (hereinafter "Provider"), and Patient Name: , residing at: (hereinafter "Patient"). Effective Date:

1. Definitions and Purpose

1.1 Definitions. For purposes of this Agreement, "Services" means the medical assessment, diagnostic testing, treatment, therapy and any related professional services described in Section 2. "Protected Health Information" or "PHI" has the meaning given under applicable health privacy law.

1.2 Purpose. Provider agrees to deliver the Services to Patient in accordance with applicable professional standards, and Patient agrees to receive such Services and to comply with the terms of this Agreement.

2. Scope of Services

Provider shall perform Services at the following location(s):

3. Term and Termination

This Agreement commences on the Effective Date and continues until Services are completed or this Agreement is terminated in accordance with this Section. Either party may terminate for cause upon written notice if the other party materially breaches the Agreement and fails to cure within thirty (30) days after receipt of written notice of such breach. Either party may terminate without cause upon sixty (60) days' prior written notice.

4. Fees, Billing and Payment

Patient is responsible for all charges not covered by insurance, including co-payments, deductibles, co-insurance, and services determined not to be medically necessary. If Patient fails to pay undisputed charges when due, Provider may suspend Services and pursue collection, and Patient shall be responsible for reasonable collection costs and attorneys' fees.

5. Insurance Assignment and Authorization

Patient authorizes Provider to submit claims to Patient's health insurer and assign benefits and payments directly to Provider to the extent permitted by law. Patient authorizes Provider to release PHI as necessary to process claims and obtain payment.

6. Confidentiality; HIPAA Authorization

Provider shall maintain confidentiality of PHI and shall use and disclose PHI only as permitted by law and this Agreement. Patient authorizes Provider to disclose PHI to insurers, consultants, and as required by law. Patient acknowledges receipt of Provider's privacy practices and consents to the uses and disclosures described herein.

This authorization is valid until: unless revoked earlier in writing. Patient understands that revocation will not affect disclosures made prior to revocation.

I acknowledge I have received and reviewed Provider's Notice of Privacy Practices and consent to the uses and disclosures described therein.

7. Consent to Treatment and Medical Information

Patient consents to the examination, diagnostic procedures, and treatment deemed advisable by Provider. Patient represents that all medical information provided to Provider is accurate and complete to the best of Patient's knowledge.

8. Patient Information

9. Warranties, Liability and Indemnification

Provider represents that it is duly licensed to perform the Services. EXCEPT AS EXPRESSLY SET FORTH IN THIS AGREEMENT, THE SERVICES ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND. TO THE MAXIMUM EXTENT PERMITTED BY LAW, PROVIDER'S LIABILITY FOR DIRECT DAMAGES ARISING OUT OF OR RELATED TO THIS AGREEMENT SHALL NOT EXCEED THE AMOUNTS PAID BY PATIENT TO PROVIDER FOR THE SPECIFIC SERVICES GIVING RISE TO THE CLAIM. NEITHER PARTY SHALL BE LIABLE FOR INCIDENTAL, CONSEQUENTIAL, OR PUNITIVE DAMAGES.

Patient agrees to defend, indemnify and hold harmless Provider and its agents against claims arising from Patient's negligence, failure to follow instructions, or inaccurate medical history.

10. Dispute Resolution and Governing Law

Any dispute arising out of or relating to this Agreement shall be resolved first through good faith negotiation between the parties. If unresolved, disputes shall be submitted to binding arbitration administered in the county where Provider maintains its primary place of business, governed by the laws of the state in which Provider is located. Each party shall bear its own costs and attorneys' fees, except that the arbitrator may award fees where authorized by law.

11. Notices

Notices under this Agreement must be in writing and delivered to the addresses set forth below. Notice is effective upon receipt.

12. Miscellaneous Provisions

Entire Agreement: This Agreement, together with any attachments or executed authorizations, constitutes the entire agreement between the parties and supersedes all prior agreements. Amendment: This Agreement may be amended only in a writing signed by both parties. Severability: If any provision is held invalid, remaining provisions shall remain in effect.

Acknowledgment

By signing below, Patient acknowledges that Patient has read and understands this Agreement, has had an opportunity to ask questions, and consents to the Services and disclosures described herein. Provider certifies that the undersigned representative is authorized to enter into this Agreement on Provider's behalf.

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