Healthcare Orthodontic Contract

HEALTHCARE ORTHODONTIC TREATMENT AGREEMENT

This Orthodontic Treatment Agreement ("Agreement") is entered into between Orthodontic Practice Name: and Patient Name: . The effective date of this Agreement is: .

Patient Information

Insurance Information

Medical History

Scope of Treatment and Acknowledgment of Risks

Provider will perform orthodontic services as described in the proposed Treatment Plan:

Patient acknowledges that orthodontic treatment involves foreseeable risks, including but not limited to root resorption, tooth mobility, relapse, soft tissue injury, changes to occlusion, and the potential need for additional treatment. Patient has had an opportunity to ask questions and understands that results cannot be guaranteed.

Treatment Timeline and Appliances

Estimated duration of active treatment is: . This estimate may be adjusted due to biological response or patient noncompliance.

Financial Terms and Insurance

Total estimated professional fee for orthodontic services is $. Payment obligations and schedule are as follows.

Monthly payment amount: $ over months. Interest rate (if any): .

Patient authorizes assignment of insurance benefits to Provider: Yes. Patient understands that Provider will bill insurance as a courtesy and that patient remains financially responsible for any portion not paid by insurance, including co-payments, deductibles, and non-covered services.

Patient Responsibilities

Patient agrees to follow Provider's written and verbal instructions regarding appliance care, attendance at scheduled visits, oral hygiene, and dietary restrictions. Failure to comply may result in extended treatment time and additional charges.

Consent, Releases and Legal Provisions

Patient hereby consents to the performance of the orthodontic procedures described above and authorizes Provider and staff to take radiographs, photographs, impressions, and records as necessary for diagnosis and treatment. Patient grants permission for the use of diagnostic materials for treatment and professional purposes.

Patient authorizes release of pertinent health information to insurance carriers for claims processing and to other health care providers as necessary for treatment coordination. Patient acknowledges receipt of Provider's privacy practices and understands how health information will be used and disclosed.

Limitation of Liability: Provider's liability for any claim arising from services performed under this Agreement shall be limited to the total fees actually paid by Patient to Provider for the services at issue, except where prohibited by law. Provider shall not be liable for consequential or incidental damages.

Default and Remedies: If Patient fails to make payments when due or otherwise breaches this Agreement, Provider may suspend treatment, impose late fees, terminate treatment, and pursue collection remedies. Patient shall be responsible for collection costs and reasonable attorneys' fees incurred in enforcing payment.

Dispute Resolution: The parties agree to submit disputes arising under this Agreement to final and binding arbitration administered in accordance with applicable arbitration rules, except where prohibited by law. Judgment on arbitration award may be entered in any court of competent jurisdiction.

Governing Law: This Agreement shall be governed by and construed in accordance with the laws of the state where the Provider's office is located.

Entire Agreement: This Agreement, including any treatment plan and financial addendum, constitutes the entire agreement between the parties and supersedes prior oral or written statements. Amendments must be in writing and signed by Patient and an authorized representative of Provider.

HIPAA and Authorization

Patient acknowledges receipt of the Provider's Notice of Privacy Practices and authorizes Provider to use and disclose protected health information for treatment, payment, and health care operations. Patient may revoke this authorization in writing at any time, except to the extent that Provider has already relied on it.

Patient consents to clinical photography for treatment records and potential educational purposes with de-identification unless Patient authorizes otherwise.

I acknowledge that risks and alternatives have been explained and I consent to the proposed treatment.
I accept financial responsibility for charges not covered by insurance.
I agree that disputes will be resolved by arbitration as stated above.

Signature and Certification

By signing below, Patient certifies that all information provided is accurate to the best of their knowledge, that they have read and understand this Agreement, and that they accept the terms and financial obligations set forth herein.

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