Healthcare Medical Project Quote

HEALTHCARE MEDICAL PROJECT QUOTE

Quote Number:    Date Prepared:

Client / Patient Information

Date of Birth:    Gender:

Phone:    Email:

Relationship:    Phone:

Insurance Information

Policy Number:    Group Number:

Project Summary & Location

Proposed Start Date:    Estimated Completion Date:

Contact Phone:    Contact Email:

Scope of Work

Provide a concise description of the services, equipment, or modifications to be supplied. The scope below establishes the deliverables that are included within this quote. Any work outside this scope will require a written change order and may incur additional charges.

Itemized Estimate

Enter each item, quantity and unit price. Line totals must reflect unit price multiplied by quantity.

Subtotal:    Taxes (if applicable):    Total Estimate:

Exclusions, Assumptions & Change Orders

Payment Terms

The following payment structure governs this quote. Acceptance by signature constitutes authorization to proceed under these terms. All amounts are due in United States currency unless otherwise specified.

Warranty, Liability & Compliance

The provider warrants materials and workmanship for the period specified in the final contract. Warranty coverage is limited to repair or replacement at provider discretion. Provider's liability for claims arising from performance of the work, whether in contract, tort, or otherwise, shall be limited to direct damages not to exceed the total amount paid under this quote. Neither party shall be liable for consequential, incidental, or punitive damages.

The provider shall comply with all applicable federal, state, and local laws, regulations and standards for healthcare facilities, including applicable privacy and data security requirements when handling protected health information.

HIPAA & Confidentiality Acknowledgment

The parties acknowledge that, in the performance of services, the provider may receive or have access to protected health information ("PHI"). Provider agrees to maintain administrative, physical, and technical safeguards to protect PHI in accordance with applicable privacy laws. Client acknowledges and authorizes the limited use and disclosure of PHI necessary to perform the services described in this quote.

  I acknowledge receipt of the confidentiality and HIPAA provisions above and authorize disclosure of PHI as required to carry out the project.

Authorization & Expiration

This quote is an offer to perform the described services at the prices stated. Acceptance must be provided in writing and signed by the client. This quote will expire if not accepted by the Expiration Date set below. Acceptance by signature constitutes authorization to proceed and agreement to the terms contained herein.

Expiration Date:

Acceptance

By signing below, the Client (Patient or authorized representative) accepts this Healthcare Medical Project Quote in its entirety, authorizes the provider to proceed with the work upon receipt of required deposit, and certifies that the information provided herein is true and accurate to the best of their knowledge. Client further acknowledges responsibility for payments as set forth in the Payment Terms section.

Sign Now