Healthcare Medical Center Agreement

HEALTHCARE MEDICAL CENTER AGREEMENT

This Healthcare Medical Center Agreement (the Agreement) is entered into between the parties identified below. The Medical Center will provide clinical services, administrative support, and related healthcare services to the Patient under the terms, covenants and conditions set forth herein.

Parties and Effective Date

Medical Center Name:

Medical Center Address:

Patient Name:

Effective Date: Month Day Year

Scope of Services

The Medical Center will provide medical evaluation, diagnostic testing, treatment, and ancillary services as clinically appropriate for the Patient. Services include, but are not limited to, consultations, examinations, procedures, medication administration, and referrals to specialists when necessary. The exact nature and extent of services will be determined by clinical staff in accordance with prevailing standards of care.

Patient Information

Month Day Year

Emergency Contact

Insurance Information

Month Day Year

Medical History

Financial Terms and Billing

The Patient authorizes the Medical Center to bill insurance and to collect co-payments, deductibles, and any patient-responsible balances. The Patient remains financially responsible for charges not covered by insurance, for services rendered in good faith, and for collection costs and reasonable attorney fees if applicable.

The Medical Center will provide itemized billing statements upon request. If insurance claim is denied, the Patient agrees to cooperate in appeals and to pay amounts due upon receipt of statement. The Medical Center may use third-party billing services and collect through customary collection efforts for overdue accounts.

Consent to Treatment and Acknowledgments

The Patient voluntarily consents to the evaluation and medical treatment recommended by authorized Medical Center personnel. The Patient acknowledges that risks, benefits, and alternatives have been explained in a manner the Patient understands. The Patient retains the right to refuse or withdraw consent at any time, subject to clinical judgment and safety considerations.

I consent to diagnostic procedures and medical treatment as deemed necessary by treating clinicians.

I acknowledge that risks, benefits and alternatives were explained and I had the opportunity to ask questions.

HIPAA Authorization and Privacy Acknowledgment

The Patient authorizes the Medical Center to use and disclose protected health information (PHI) as necessary for treatment, payment, and healthcare operations. The Patient acknowledges receipt of the Medical Center’s privacy practices and understands that PHI will be disclosed in accordance with applicable law and the Medical Center’s privacy policies.

Month Day Year

Release relevant records to Emergency Contact
Release relevant records to Primary Care Physician listed above

Liability, Indemnification and Termination

The Medical Center will exercise reasonable care in providing services but makes no warranty, express or implied, beyond the standard of care. The Patient agrees to release and hold harmless the Medical Center and its employees for ordinary negligence except where prohibited by law. The Patient agrees to indemnify the Medical Center for claims arising from the Patient’s willful misconduct. Either party may terminate this Agreement upon written notice; termination does not relieve the Patient of liability for services already rendered.

Governing Law and Dispute Resolution

This Agreement is governed by the laws of the state identified by the Medical Center and Patient for governing law purposes. The parties agree to attempt good faith resolution of disputes through negotiation, and, if unresolved, through mediation prior to initiating litigation, unless otherwise required by law.

Notices

Cancellation, No-Show and Infection Control Policies

The Patient agrees to comply with the Medical Center’s scheduling, cancellation and infection control policies. Failure to attend scheduled appointments without timely cancellation may result in fees or discharge from the practice. The Medical Center reserves the right to refuse or modify services to maintain safety and infection control standards.

Certification and Signature

By signing below, each party certifies that they have the authority to enter into this Agreement, that the information provided in this form is true and correct to the best of their knowledge, and that they accept the terms set forth in this Agreement.

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