Healthcare Patient Liaison Agreement

HEALTHCARE PATIENT LIAISON AGREEMENT

This Patient Liaison Agreement (Agreement) is entered into between the undersigned patient and the Patient Liaison Provider identified below for the purpose of coordinating communications, facilitating access to medical information, and assisting with appointment scheduling and related healthcare navigation tasks.

Parties and Effective Date

Patient Name:

Patient Address:

Liaison Organization / Representative:

Effective Date:

Definitions

For purposes of this Agreement: "Liaison Services" means facilitation of appointments, communication with providers, assistance obtaining records, clarification of billing statements, and other non-clinical coordination services specifically requested by Patient. "Protected Health Information" or "PHI" has the meaning set forth under applicable privacy law and includes medical records and health information necessary for Liaison Services.

Scope of Services

The Liaison will perform the following services as authorized by Patient (check all that apply):

Schedule and confirm medical appointments

Request and retrieve medical records and test results

Assist with billing inquiries and claims coordination

Act as an authorized communications representative with healthcare providers and payers

Patient Information

Insurance Information

Medical History (For Liaison Use)

Authorization to Access Records and Communicate

Patient hereby expressly authorizes the Liaison to receive, review and discuss Protected Health Information necessary to perform Liaison Services, including but not limited to medical records, test results, billing statements, and appointment information. This authorization includes the right to request and receive copies of records on behalf of Patient and to communicate with healthcare providers, payers, and other third parties as necessary.

This authorization is valid until:

Confidentiality and HIPAA Compliance

The Liaison agrees to comply with all applicable privacy and security laws, including requirements relating to Protected Health Information. The Liaison will implement reasonable administrative, technical and physical safeguards to protect PHI and will use PHI only to perform the Liaison Services authorized by Patient. Any further disclosure of PHI by the Liaison requires additional written authorization from Patient unless otherwise permitted by law.

Limits of Authority

The Liaison is not a healthcare provider and will not make medical decisions, provide clinical advice, or act as an agent for consent to treatment. The Liaison may only act as Patient's designated communications representative to the extent expressly authorized in this Agreement.

Fees and Compensation

Compensation for Liaison Services (if any): . If no fee, enter "No Fee".

Payment responsibility and billing arrangements shall be as set forth in a separate fee agreement between Patient and Liaison, or as indicated above.

Term and Termination

This Agreement commences on the Effective Date and shall continue until terminated by either party upon written notice. Patient may revoke this authorization at any time by delivering written notice to the Liaison, subject to actions already taken in reliance on this Agreement.

Indemnification and Liability

Each party agrees to indemnify and hold harmless the other party from and against any claims, liabilities or expenses arising from its breach of this Agreement or its negligent acts or omissions in connection with the performance of duties under this Agreement. The Liaison's liability for direct damages shall be limited to the amount of fees paid by Patient for the particular Liaison Services giving rise to the claim, except where prohibited by law.

Records Retention

The Liaison will maintain a record of communications and disclosures made pursuant to this Agreement for a minimum period required by applicable law and will provide copies to Patient upon request subject to reasonable administrative fees.

Acknowledgment

By signing below, Patient acknowledges that they have read and understand this Agreement, authorize the Liaison as set forth herein, and consent to the use and disclosure of PHI as necessary to perform Liaison Services.

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