Healthcare Pediatric LOI

HEALTHCARE PEDIATRIC LETTER OF INTENT

Parties and Patient Information

Patient Name:

Date of Birth:    Gender:

Referring and Receiving Parties

Program / Service Description

Brief description of requested services, interventions, or program:

Primary clinical goals and expected outcomes:

Anticipated Schedule and Duration

Anticipated initiation date:    Anticipated completion/transition date:

Medical and Insurance Information

Authorization and Release

By signing below, the undersigned parent or legal guardian hereby authorizes the exchange of medical, behavioral, and educational records necessary to evaluate and coordinate the pediatric services described herein. This authorization includes but is not limited to diagnostic assessments, treatment plans, progress notes, and discharge summaries.

Release authorized to:

Authorize release of medical records

Authorize release of educational records

This authorization expires on:

Confidentiality, HIPAA Acknowledgment, and Consent to Treatment

The parties acknowledge that health information disclosed under this Letter of Intent is protected under privacy laws and regulations. The receiving program agrees to treat information in accordance with applicable confidentiality and privacy obligations.

I acknowledge receipt of the program's privacy practices and understand that information necessary for treatment coordination may be shared with the referring provider and payer(s) as authorized above.

Consent to provision of routine and emergency pediatric care, including assessment and interventions specified in this LOI, is granted by my signature below. I understand the nature and purpose of the services, reasonably foreseeable risks and benefits, and my right to ask questions and withdraw authorization at any time by providing written notice to the receiving program.

I consent to treatment and coordination as described above.

Financial Responsibility and Billing

Responsibility for fees, co-payments, deductibles, and charges not covered by insurance remains with the subscriber or guarantor unless otherwise agreed in writing. The receiving program will attempt to verify benefits and obtain pre-authorizations but verification does not guarantee payment by an insurer.

Non-Binding Intent, Terms and Termination

This Letter of Intent is intended to document the current intent of the parties to pursue evaluation and, if appropriate, admission and treatment in the described program. Except for the authorization and release provisions and confidentiality obligations expressly set forth herein, this document is non-binding and does not create a contract to provide services or a guarantee of admission. Either party may withdraw or modify this LOI upon written notice to the other party prior to execution of a definitive agreement or admission.

The receiving program retains the right to decline services based on clinical assessment, safety considerations, or eligibility criteria. Nothing in this LOI limits emergency care obligations required by applicable law.

Representations and Certification

The undersigned certifies that the information provided in this Letter of Intent is true and accurate to the best of their knowledge. The undersigned further affirms they are the parent or legal guardian authorized to execute this document on behalf of the named patient and to provide the consents and authorizations contained herein.

Sign Now