Healthcare Monthly Service Agreement

HEALTHCARE MONTHLY SERVICE AGREEMENT

This Healthcare Monthly Service Agreement (the "Agreement") is entered into between Provider Name: and Client Name: . Effective Date: .

1. Scope of Services

Provider will furnish the healthcare services described below on a recurring monthly basis in accordance with professional standards and applicable law. Services shall be limited to those expressly described in the Service Description field and any attachments incorporated by reference.

2. Term; Renewal; Cancellation

The initial term of this Agreement shall commence on the Effective Date and continue month-to-month until terminated in accordance with this Agreement. Either party may terminate without cause upon providing written notice no less than days prior to the desired termination date. Provider may suspend services immediately for nonpayment or where continuation would create a material risk to the health or safety of the client or staff.

3. Fees; Billing; Payment

Client agrees to pay Provider a monthly service fee of $ due on the day of each month. Fees are due regardless of insurance payment unless Provider has accepted assignment of benefits in writing.

Credit card on file    ACH / Bank transfer    Monthly invoice

Late payments shall accrue interest at or the maximum allowed by law, whichever is less. Returned payment fee: $ .

4. Insurance and Assignment

Provider may bill Client's insurance when applicable. Client shall provide accurate insurance information and cooperate with claims submission. Provider's acceptance of insurance billing does not relieve Client of responsibility for payment.

Assignment of benefits to Provider: I authorize payment of insurance benefits directly to Provider (if applicable).

5. Patient Information & Emergency Contact

6. Medical History

7. Confidentiality; HIPAA Authorization and Acknowledgment

Provider maintains protected health information (PHI) in accordance with applicable privacy laws. By signing this Agreement, Client acknowledges receipt of Provider's Notice of Privacy Practices and authorizes Provider to use and disclose PHI as necessary to provide services, process claims, and coordinate care.

Client grants Provider permission to communicate health information to designated persons:

Authorization expires on: . Client may revoke this authorization in writing at any time, except to the extent Provider has already acted in reliance on the authorization.

Acknowledgment: I acknowledge I have received and had the opportunity to review the Provider's Notice of Privacy Practices.

8. Risk Allocation; Indemnification; Limitation of Liability

Provider shall perform services in a professional manner consistent with applicable standards. Client acknowledges that no warranty of specific results is made. Client agrees to release and hold harmless Provider, its employees and contractors from liability for ordinary negligence to the extent permitted by law. Client shall indemnify Provider for third-party claims arising from Client's acts or omissions.

9. Termination for Cause; Remedies

Either party may terminate for material breach if the breach remains uncured for more than days after written notice. Termination shall not relieve Client of liability for fees accrued prior to termination. All remedies available at law or equity are preserved.

10. Governing Law; Dispute Resolution

This Agreement shall be governed by the laws of the state of without regard to conflict of laws principles. Parties shall first attempt to resolve disputes through good faith negotiation. If unresolved, disputes shall be resolved by binding arbitration in the foregoing state unless otherwise agreed in writing.

11. Notices

12. Miscellaneous

Entire Agreement: This Agreement, including any attachments and any signed service plans, constitutes the entire agreement between the parties and supersedes prior agreements. Modifications must be in writing and signed by both parties. If any provision is held invalid, the remainder of the Agreement will remain in effect.

Acknowledgment and Consent

By signing below, Client confirms that the information provided in this Agreement is accurate to the best of Client's knowledge, consents to the provision of the described services, and acknowledges understanding of billing, termination, and privacy provisions herein.

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