Healthcare Offer Form

HEALTHCARE OFFER FORM

Provider and Offer Identification

Offer Number:    Offer Date:    Offer Valid Through:

Patient Information

Date of Birth:    Gender:

Phone:    Email:

Relationship:    Phone:

Insurance and Billing

Policy / ID Number:    Group Number:

The Provider requests assignment of benefits and authorization to bill insurance on the patient’s behalf. By accepting this Offer the patient authorizes the Provider to submit claims and to retain payments from the insurer for services rendered, except where prohibited by law.

Offer of Services — Scope, Fees, and Terms

Payment Terms:

This Offer constitutes an offer to provide the services described above at the fees and on the terms set forth herein. Acceptance of the Offer creates a binding agreement for medical services between the Provider and the Patient, subject to any insurer determinations and applicable law.

Medical History

Consent, Risks, and Patient Rights

The Provider has provided the Patient with a description of the proposed services, expected benefits, material risks, likely alternatives and risks of not undergoing treatment. The Patient acknowledges that no guarantee as to outcome has been made. The Patient retains the right to withdraw consent at any time prior to or during treatment, subject to reasonable steps to ensure patient safety.

By checking the box below and signing, the Patient affirms that they have read and understand the description of services, risks and benefits, and agree to proceed under the terms of this Offer.

I accept the Offer as described above and authorize the Provider to provide the specified services.

HIPAA / Privacy Acknowledgment

The Patient acknowledges receipt of the Provider’s Notice of Privacy Practices describing how medical information may be used and disclosed and the Patient’s rights with respect to protected health information. The Patient authorizes the Provider to use and disclose protected health information for treatment, payment and health care operations as described in that notice.

I acknowledge receipt of the Notice of Privacy Practices and consent to the uses and disclosures described therein.

Authorization and Limitations

Authorization to Bill Insurance and Release of Information: The Patient authorizes the Provider to release medical and billing information necessary to process claims and authorizes payment of benefits to the Provider unless otherwise noted in writing.

Limitation of Liability: Except as prohibited by law, Provider liability for any claim arising under or related to services covered by this Offer shall be limited to direct damages not exceeding the amount paid by or on behalf of the Patient for the specific service in dispute.

Cancellation and No-Show Policy: The Provider may assess cancellation or no-show fees according to their standard policy. Charges for missed appointments or late cancellations that are not covered by insurance remain the Patient’s responsibility.

Acknowledgment and Certifications

By signing below the Patient certifies that the information provided on this form is true and complete to the best of their knowledge. The Patient understands that charges for services rendered may not be fully covered by insurance and agrees to pay amounts for which the Patient is responsible under the Provider’s billing practices.

If signed by an authorized representative, the signer certifies authority to sign on behalf of the Patient and agrees to provide supporting documentation upon request.

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