Healthcare Offer Document

HEALTHCARE OFFER DOCUMENT

This Healthcare Offer Document (the Offer) sets forth the terms under which the Provider identified below offers to provide healthcare services to the Patient identified below. Acceptance of this Offer by signature creates a binding agreement between the parties for the services and terms specified herein.

Provider and Patient Information

Date of Birth:    Gender:

Offer Summary — Services and Schedule

Description of services to be provided (scope, modality, frequency). The Provider offers to provide the following services under the terms below:

Anticipated Start Date:    Estimated Completion or Review Date:

Insurance and Financial Terms

Estimated total cost for the services described above: $    Estimated patient out-of-pocket responsibility: $

Billing and Payment Terms: Provider will bill insurance as a courtesy where permitted. The Patient remains responsible for copayments, coinsurance, deductibles, and amounts not covered by insurance. Payment is due according to Provider's billing policy and may be required prior to certain services.

Medical History & Administrative Information

Risks, Benefits, and Alternatives

The Provider has explained the nature, purpose, expected benefits, reasonably foreseeable risks, and reasonable alternatives to the proposed services. The Patient understands that no guarantee of outcome is provided and that complications or adverse events, while not expected, can occur. The Patient has the right to ask questions and to withdraw consent at any time prior to delivery of services.

I acknowledge that the risks, benefits, and alternatives have been explained to me and I have had the opportunity to ask questions.

Privacy, Authorization, and HIPAA Acknowledgment

The Patient authorizes the Provider to use and disclose protected health information for treatment, payment, and healthcare operations consistent with applicable law. The Patient understands that a separate signed authorization is required for disclosures not permitted by law. This Offer includes acknowledgment of receipt of the Provider's Notice of Privacy Practices.

I acknowledge receipt of the Provider's Notice of Privacy Practices and authorize use/disclosure as described above.

Offer Validity, Termination, and Modifications

This Offer is valid until: . The Provider may withdraw or amend this Offer prior to acceptance in writing. Upon acceptance by signature, this Offer constitutes the agreement between the parties and may be modified only by a subsequent written instrument signed by both parties.

Legal Terms

Governing Law and Venue: This Offer and any resulting agreement are governed by the laws of the state in which the Provider is located, without regard to conflict of laws principles. Any dispute arising out of this Offer shall be subject to the exclusive jurisdiction of the state and federal courts located within the Provider's jurisdiction.

Indemnification: The Patient agrees to indemnify and hold harmless the Provider for any claims arising from inaccurate information provided by the Patient or failure to follow reasonable medical instructions, except to the extent caused by Provider negligence.

Severability and Entire Agreement: If any provision of this Offer is held invalid, the remaining provisions shall remain in full force. This Offer constitutes the entire agreement between the parties regarding the services described herein.

Acceptance and Signature

By signing below, the parties confirm that they have read and understand this Offer, that the information provided is accurate, and that acceptance creates a binding agreement for the services and terms set forth above.

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