Healthcare Phase I Contract

HEALTHCARE PHASE I CONTRACT

Parties and Contract Date

This Healthcare Phase I Contract (the "Agreement") is entered into between Provider Name: and Patient Name: Effective Date:

Provider Contact & Credentials

Patient Information

Insurance Information

Medical History

Scope of Phase I Services

Provider will perform initial Phase I services consisting of evaluation, baseline testing, specified clinical procedures, and monitoring as described below. Description:

Start Date:    Estimated Completion Date:

Fees, Billing and Payment

Patient agrees to pay fees for Phase I services as set forth below. If covered by insurance, Provider will bill the insurer. Patient remains responsible for any copayment, deductible, or non-covered services.

Insurance will be billed: Yes    Patient Estimated Responsibility:

Consent, Risks, and Withdrawal

Patient acknowledges receipt of a description of Phase I procedures, anticipated benefits, and reasonably foreseeable risks. Patient understands the right to withdraw from Phase I services at any time without penalty to future care.

By signing below, Patient provides informed consent for the Phase I services described above and acknowledges they have had an opportunity to ask questions and receive answers satisfactory to the Patient.

Consent to treatment: I consent to receive Phase I services    Consent to use of de-identified data: I consent to use of de-identified data for research/quality improvement

Privacy, Confidentiality, and HIPAA Authorization

Provider will maintain patient health information in accordance with applicable privacy laws and Provider's privacy policies. Patient hereby authorizes Provider to use and disclose protected health information as required for treatment, payment, and healthcare operations and as described in this Agreement.

Patient acknowledges they may revoke this authorization in writing at any time except to the extent Provider has already acted in reliance upon it. Revocation will not affect disclosures made prior to Provider's receipt of the revocation.

Liability, Indemnification and Limitation of Damages

Provider will exercise reasonable clinical judgment and conform to prevailing standards of care. Patient agrees to indemnify and hold Provider harmless from claims arising from Patient's failure to disclose material medical information or to follow pre- or post-procedure instructions. Except to the extent prohibited by law, Provider's liability for claims arising under this Agreement shall be limited to direct damages not to exceed the total fees paid for Phase I services under this Agreement.

Data Use, Records and Ownership

Medical records created in connection with Phase I services are the property of the Provider, subject to patient access rights under applicable law. Provider may use de-identified data for research, quality improvement, or publication without further consent, unless otherwise restricted in writing.

Termination and Amendment

Either party may terminate Phase I services for any reason upon written notice. Provider may terminate immediately for reasons related to patient safety or non-payment. This Agreement may be amended only by a written document signed by both parties.

Governing Law and Notices

This Agreement shall be governed by the laws of: without regard to conflict of law principles. Notices required by this Agreement shall be sent to the contact addresses provided above.

Severability

If any provision of this Agreement is found to be invalid or unenforceable, the remaining provisions will continue in full force and effect.

Certifications and Patient Declarations

I certify that the information provided in this Agreement and accompanying medical history is true and complete to the best of my knowledge. I authorize Provider to perform the Phase I services described and to bill my insurer where applicable.

Sign Now