Healthcare Phase 1 Agreement

HEALTHCARE PHASE 1 AGREEMENT

Patient Information

Date of Birth:    Gender: Female   Male   Other

Insurance and Billing

Insurance Provider:

By signing this Agreement the patient (or responsible party) acknowledges financial responsibility for charges not covered by insurance, including co-payments, deductibles, non-covered services and services denied by the insurer. Patient agrees to provide current insurance information and to notify provider of changes.

Phase 1 Services — Description and Scope

Phase 1 consists of initial evaluation, diagnostic testing as required, formulation of a preliminary treatment plan, and limited therapeutic interventions intended to assess patient response. Specific procedures included in Phase 1 (select all that apply):

Clinical evaluation and history   Laboratory testing   Imaging studies   Initial therapeutic intervention

Risks, Benefits, and Alternatives

The patient acknowledges that Phase 1 interventions carry potential risks, which may include but are not limited to discomfort, allergic reaction, infection, unanticipated diagnostic findings, or lack of clinical benefit. The patient has been informed of the expected benefits and reasonable alternatives, including the option of no treatment or referral to another provider. Patient has had the opportunity to ask questions and understands that not all risks can be listed here.

Medical History

Consent and Authorization

By signing below the patient (or legal representative) consents to the provision of Phase 1 services described above by the treating provider. This consent includes authorization for necessary examinations, diagnostic tests, and treatments consistent with the accepted standard of care. Consent is voluntary and may be withdrawn in writing at any time, except to the extent that action has already been taken in reliance on this consent.

HIPAA and Privacy: The patient acknowledges receipt of the provider's privacy practices and authorizes the use and disclosure of protected health information as necessary for treatment, payment and healthcare operations. The patient authorizes release of information to other treating providers and insurers as required for continuity of care and claims processing. This authorization is valid until the expiration date below unless revoked earlier in writing.

Authorization to Communicate: I authorize the provider to communicate appointment reminders, test results, and clinical information via the contact methods provided above. If I do not authorize, I decline such communications.

I authorize communications via phone and email   I decline communications by phone/email

Additional Terms

Withdrawal and Termination: The patient may withdraw consent at any time by written notice. The provider reserves the right to terminate services if the patient fails to comply with recommended care, fails to attend scheduled appointments, or engages in behavior that jeopardizes staff or other patients.

Liability: To the fullest extent permitted by law, the provider's liability for services under this Agreement shall be limited to direct damages and shall exclude consequential or punitive damages. Nothing in this clause limits rights that cannot be waived by law.

Acknowledgement and Signature

I certify that the information I have provided is true and complete to the best of my knowledge. I have read and understand the terms of this Healthcare Phase 1 Agreement, including risks, benefits, financial responsibility, and privacy authorizations. I consent to the Phase 1 services as outlined unless otherwise indicated in writing below.

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