Healthcare Nursing Quote

HEALTHCARE NURSING QUOTE

Provider Information

Client / Patient Information

Client Name:    Date of Birth:

Insurance Information

Provider will bill insurance where authorized. Client acknowledges that coverage verification and benefit determination are estimates only and that Client is financially responsible for charges not paid by insurance. Authorization to bill insurance: Yes

Medical Summary & Needs Assessment

Proposed Nursing Services & Fees

Service Start Date:    Estimated Service End Date:

Nursing Levels (select all that apply):
Registered Nurse (RN)    Licensed Practical Nurse (LPN)    Certified Nursing Assistant (CNA)    Home Health Aide (HHA)

Additional Fees: Travel/ mileage: ; Supplies: ; Overnight/Shift Differential:

Terms, Conditions & Disclosures

Scope of Services: Provider will furnish professional nursing and attendant services described above and consistent with the patient assessment and applicable professional standards. Services do not include surgical procedures, in-patient hospital care, or other services outside the provider's licensure unless specifically agreed in writing.

Payment Terms: Client agrees to pay Provider for services rendered according to the rates set forth above. Provider may require a deposit prior to initiation of services. Invoices are payable within 30 days unless otherwise agreed in writing. Unpaid balances may be subject to interest and collection costs.

Cancellation & Schedule Changes: Cancellations made less than 24 hours prior to a scheduled shift may be billed at the full hourly rate for the scheduled hours. Provider will make reasonable efforts to provide substitute personnel when available.

Liability & Insurance: Provider maintains professional liability and workers' compensation insurance for personnel provided. Provider's liability for claims arising from this agreement is limited to the amount of fees paid for the specific services giving rise to the claim, except as prohibited by law.

Background & Credentials: Provider warrants that personnel assigned possess applicable licensure, certifications, and training. Client may request verification of credentials prior to commencement of services.

Privacy, HIPAA & Confidentiality

Provider will maintain the confidentiality of Client's protected health information and will use and disclose such information only as permitted by law and as necessary to provide services and for billing, treatment, and operations. By signing below, Client acknowledges receipt of the Provider's privacy practices and authorizes the release of necessary health information for treatment and billing purposes.

Authorization, Quote Validity & Acceptance

This quote is an estimate of services and fees based on the information available at the time of issuance. Final charges may vary with actual services provided. Quote valid until: . Acceptance of this quote authorizes Provider to schedule services and to proceed with the scope of care described herein.

Acknowledgment

By signing below, the Client (or authorized representative) certifies that the information provided is true and accurate to the best of their knowledge, that they have had the opportunity to ask questions about the proposed services and fees, and that they accept the terms, conditions, and payment obligations set forth in this quote. Client further authorizes Provider to obtain and release health information as necessary for treatment and payment.

Relationship to Patient (if signed by guardian or representative):

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