Healthcare Ongoing Contract

HEALTHCARE ONGOING CONTRACT

Parties and Effective Date

This Healthcare Ongoing Contract (the "Agreement") is entered into on this date: Day: Month: Year: , by and between Provider Name: located at and Patient Name: .

Patient Information

Insurance and Billing

Insurance Provider: Policy Number: Group Number:

Assignment of Benefits: Patient assigns insurance benefits to Provider for covered services.

Scope of Services and Schedule

Provider shall deliver ongoing healthcare services as set forth in Service Plan: . Services may include assessment, treatment, medication management, therapy, home visits, telehealth, and coordination with other health professionals as appropriate.

Frequency and Duration: . Provider will make reasonable efforts to adhere to scheduled appointments and will notify Patient of changes in advance.

Fees, Payment and Billing Procedures

Fees for services rendered shall be: Fee per visit or unit: $. Billing frequency: .

Patient is responsible for co-payments, deductibles, and services not covered by insurance. Provider may bill Patient directly for amounts not paid by insurer. Unpaid balances may be subject to collection and reasonable costs of collection.

Medical History and Current Condition

Consent, Privacy and Release

Consent to Treatment: Patient hereby consents to the provision of healthcare services by Provider as described in this Agreement. Patient understands the nature of the services, potential benefits, material risks, and alternative options, and has had an opportunity to ask questions.

HIPAA Authorization: Patient authorizes Provider to use and disclose protected health information for treatment, payment, and healthcare operations, and acknowledges receipt of Provider's Notice of Privacy Practices.

Termination and Modification

Term: This Agreement continues until terminated by either party upon written notice. Either party may terminate for convenience with at least days' written notice. Provider may terminate immediately for nonpayment or material breach.

Amendment: Any amendment to this Agreement must be in writing and signed by both parties. Assignment by Provider requires notice to and reasonable assent from Patient where required by law.

Liability, Indemnification and Dispute Resolution

Limitation of Liability: To the extent permitted by law, Provider's total liability for claims arising from services under this Agreement shall be limited to direct damages not to exceed the total fees paid by Patient to Provider in the six (6) months preceding the claim.

Indemnification: Each party shall indemnify and hold harmless the other against claims arising from its negligent acts, omissions, or willful misconduct in the performance of this Agreement.

Dispute Resolution: The parties shall first attempt to resolve disputes through good faith negotiation. If unresolved, disputes shall be submitted to mediation prior to filing litigation, unless injunctive relief is sought.

Notices

Miscellaneous

Governing Law: This Agreement shall be governed by and construed in accordance with the laws of the state of: .

Entire Agreement: This Agreement constitutes the entire understanding between the parties relating to its subject matter and supersedes prior agreements and understandings between the parties relating to that subject matter.

Acknowledgment

By signing below, each party certifies that they have the authority to enter into this Agreement, have read and understand its terms, and agree to be bound by its provisions.

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