Healthcare Medical Contract Update

HEALTHCARE MEDICAL CONTRACT UPDATE

This Medical Contract Update (the Update) is entered into by and between Provider Name: and Patient Name: . The updated terms set forth herein become effective as of Effective Date: .

Purpose and Scope of Update

Purpose: The Provider and Patient agree that the existing Patient Service Agreement is amended by this Update to modify the specific terms set forth below. This Update supersedes any prior inconsistent provisions of the existing agreement to the extent explicitly amended herein. All other terms remain in full force and effect unless expressly replaced by this Update.

Patient Information

Insurance Information

Medical History (for administrative update)

Updated Terms and Authorizations

1. Billing and Patient Financial Responsibility: Patient acknowledges that the Provider may amend billing practices. Patient agrees to be responsible for copayments, deductibles, and charges not covered by insurance in accordance with the updated fee schedule attached to this Update or as provided in writing. Updated patient responsibility percentage:

2. Assignment of Benefits and Insurance Claims: Patient hereby assigns to Provider all rights to receive payment from Patient's insurer for health care services provided by Provider, and authorizes Provider to file claims on Patient's behalf. Patient confirms that insurance information above is current and authorizes Provider to obtain payment directly from Patient's insurer.

3. Telehealth Services: Patient consents to the provision of health care services via telehealth where clinically appropriate. Patient understands risks and limitations of telehealth. Consent to telehealth:

4. Prescription and Controlled Substances: Patient acknowledges any changes to prescribing policy, including documentation and monitoring requirements. Patient agrees to comply with prescription monitoring and follow-up protocols as required by Provider.

5. Release of Records for Continuity of Care: Patient authorizes the Provider to release and exchange medical records with other health care providers and payors to facilitate treatment and claim adjudication. This authorization shall remain effective until Authorization Expiration Date:

6. Electronic Communication and Billing: Patient consents to receive appointment reminders, billing statements, and clinical messages via electronic means, including email or SMS, subject to Provider's privacy practices. Patient may revoke electronic communication consent in writing; revocation does not affect communications already sent.

HIPAA Privacy Acknowledgment

Patient acknowledges receipt of Provider's Notice of Privacy Practices and understands how protected health information may be used and disclosed. Patient understands the rights to request restrictions, receive confidential communications, and obtain copies of records as provided under applicable privacy laws. Patient acknowledges:

Right to Withdraw and Modifications

Patient may revoke consents and authorizations granted in this Update by delivering written notice to Provider, subject to limitations where Provider has relied on such consents or where revocation would violate law. Any modification to this Update must be in writing and signed by Patient and an authorized representative of Provider. Patient acknowledges receipt of a copy of this Update upon signing.

Miscellaneous

Governing law: This Update is governed by the laws of the State: . If any provision of this Update is held invalid, the remaining provisions shall continue in full force and effect. This Update, together with the existing Patient Service Agreement, constitutes the entire agreement between the parties with respect to the subject matter herein.

Acknowledgment of Updated Fee Schedule

Patient acknowledges receipt of the updated fee schedule and understands that fees for services, supplies, and ancillary charges may change consistent with the Update. Patient initial to confirm receipt:

Certification

By signing below, Patient certifies that the information provided in this Update is true and correct to the best of Patient's knowledge, that Patient has the authority to provide the authorizations set forth herein, and that Patient accepts the Updated Terms as of the Effective Date indicated above.

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