Healthcare Monthly Contract

HEALTHCARE MONTHLY CONTRACT

This Healthcare Monthly Contract (the Agreement) is entered into between Provider Name: and Patient Name: . Patient Date of Birth: .

1. CONTACT INFORMATION

2. INSURANCE INFORMATION

3. TERM AND RENEWAL

Commencement Date: . This Agreement has an initial term of months and shall automatically renew for successive one-month periods unless terminated in accordance with Section 8 below. Billing cycle: Monthly on day of each month.

By initialing below, Patient authorizes Provider to automatically charge the payment method on file each month for recurring fees and applicable taxes. Initials:

4. SERVICES AND SCOPE OF CARE

Provider will furnish personnel and supplies as described above. Any services outside the written scope require prior written authorization and may be billed separately.

5. FEES, BILLING, AND PAYMENT

Monthly Fee: $ payable in advance on each billing date. Payment Method: .

Late Payment: Any payment not received within days after the due date shall incur a late fee of and interest at the maximum rate permitted by law.

Payment Authorization: Patient authorizes Provider to charge the identified payment method for amounts due. Patient shall provide updated payment information upon request; failure to do so may result in suspension of services.

6. INSURANCE & THIRD-PARTY BILLING

Provider will bill insurance as a courtesy if authorized by Patient. Patient remains responsible for all charges not covered by insurance, including deductibles, copays and non-covered services.

7. MEDICAL HISTORY AND DISCLOSURES

8. CONSENT FOR TREATMENT

Patient consents to the provision of the services described in this Agreement, understands the nature and expected benefits of such services, and acknowledges the risks and alternatives have been explained. Patient retains the right to withdraw consent at any time by providing written notice to Provider. Withdrawal of consent does not relieve Patient of obligations for services already rendered.

9. HIPAA PRIVACY AND AUTHORIZATION

Patient acknowledges receipt of Provider's Notice of Privacy Practices and authorizes Provider to use and disclose protected health information for treatment, payment and healthcare operations as described in that notice. Patient consents to communications regarding billing and appointments by telephone and electronic means.

I acknowledge receipt of the Privacy Practices and authorize the uses described above:

10. TERMINATION AND CANCELLATION

Either party may terminate this Agreement for convenience with thirty (30) days' written notice. Provider may terminate immediately for nonpayment, material breach, or when continued services would jeopardize patient safety. Upon termination, Patient is responsible for fees for services rendered through the termination date and any costs reasonably incurred by Provider to effect termination.

11. LIMITATION OF LIABILITY; INDEMNIFICATION

To the extent permitted by law, Provider's liability for claims arising under this Agreement shall be limited to direct damages not to exceed the total fees paid by Patient under this Agreement in the six (6) months preceding the event giving rise to the claim. Provider shall not be liable for indirect, incidental, special or consequential damages. Patient agrees to indemnify and hold Provider harmless from claims arising from Patient's acts or omissions.

12. GOVERNING LAW; DISPUTE RESOLUTION

This Agreement shall be governed by the laws of the state governing the Provider's principal place of business. Parties agree to attempt in good faith to resolve disputes through informal negotiation; if unsuccessful, disputes shall be resolved by binding arbitration in accordance with the arbitration rules agreed by the parties.

13. NOTICES

Notices under this Agreement shall be in writing and delivered to the addresses set forth in Section 1. Notice is effective upon delivery by hand, electronic transmission with confirmation, or three (3) days after deposit in the U.S. mail, postage prepaid.

14. AUTHORIZATION EXPIRATION

This authorization for treatment and billing shall expire on: unless earlier revoked in writing in accordance with Provider policy.

15. MISCELLANEOUS

Entire Agreement: This Agreement constitutes the entire understanding between the parties and supersedes prior agreements. Amendments must be in writing and signed by both parties. If any provision is held invalid, the remaining provisions remain enforceable.

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