Healthcare Medical Services Contract

HEALTHCARE MEDICAL SERVICES CONTRACT

This Medical Services Contract (the "Agreement") is entered into between Provider: and Patient: on this date: . Provider agrees to deliver and Patient agrees to receive the medical services described below in accordance with the terms and conditions set forth in this Agreement.

1. Provider and Patient Information

Date of Birth:    Gender:

Relationship:    Phone:

2. Scope of Services

Provider shall perform the services described below (the "Services"). The Services shall be performed in a professional manner consistent with applicable standards of care. Specific services, frequency, and location:

3. Term; Termination

This Agreement commences on the Effective Date and continues until the Services are completed or until terminated by either party as provided below. Either party may terminate for convenience upon written notice delivered at least days prior to termination. Immediate termination is permitted for material breach, nonpayment, or conduct creating imminent risk to patient safety.

4. Fees, Billing and Payment

Patient shall pay Provider the fees set forth for Services. Standard fee schedule or flat fee:

Payment is due within days of invoice. Late payments are subject to a late fee of . Patient is responsible for any collection costs, including reasonable attorney fees.

5. Insurance and Assignment

Patient authorizes Provider to bill insurance on Patient's behalf and to release medical information necessary for claims processing. Patient understands that Provider may require payment at time of service for non-covered services, copayments, deductibles, and services denied by the insurer.

6. Medical History and Allergies

7. Consent to Treatment; Risks and Benefits

Patient consents to the provision of the Services described in this Agreement and acknowledges that Provider has explained the nature of the proposed treatment, anticipated benefits, material risks and alternatives. Patient has the right to ask questions and to withdraw consent at any time. Material risks and common complications include, but are not limited to:

Patient acknowledges that no guarantee or assurance has been made by Provider regarding results. If complications arise, Provider will inform Patient of reasonable options for treatment.

8. Confidentiality and HIPAA

Provider maintains protected health information in accordance with applicable privacy laws. By signing this Agreement, Patient acknowledges receipt of Provider's Privacy Practices Notice and authorizes the use and disclosure of health information for treatment, payment, and healthcare operations as required to fulfill the terms of this Agreement.

Authorization to disclose information to designated persons: Name: Relationship:

9. Authorization and Expiration

Patient authorizes Provider to deliver the Services and to obtain and exchange health information necessary to provide care. This authorization expires on: unless earlier revoked in writing.

10. Cancellation and No-Show Policy

Patient agrees to provide at least hours notice of cancellation. Late cancellations or no-shows may be subject to a cancellation fee of .

11. Representations; Indemnification; Limitation of Liability

Each party represents that it has the authority to enter this Agreement. Patient shall indemnify and hold harmless Provider from claims arising from Patient's failure to disclose relevant medical information or from Patient's noncompliance with treatment instructions. Except for willful misconduct or gross negligence, Provider's liability for damages arising under this Agreement shall be limited to direct damages not to exceed the total fees paid by Patient for the Services giving rise to the claim.

12. Dispute Resolution; Governing Law

The parties agree to attempt in good faith to resolve disputes informally prior to initiating formal proceedings. Any dispute not resolved informally shall be resolved by binding arbitration or litigation as selected by Provider. This Agreement shall be governed by the laws of the state in which Provider's principal office is located.

13. Notices

Notices required under this Agreement shall be delivered to the addresses listed below. Provider address:

Patient address:

14. Miscellaneous

This Agreement constitutes the entire agreement between the parties with respect to the Services and supersedes prior written or oral agreements. Amendments must be in writing and signed by both parties. If any provision is held invalid, the remainder shall remain in full force and effect.

15. Acknowledgments and Consents

By signing below, Patient acknowledges receipt of all disclosures required by law, consents to the release and use of health information as described herein, and affirms that the information provided in this Agreement is true and complete to the best of Patient's knowledge.

Patient affirmations:
I acknowledge receipt of Provider's Privacy Practices Notice.
I authorize Provider to bill my insurance and to retain payment for services rendered.
I certify that the medical history and insurance information provided are accurate to the best of my knowledge.

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