Healthcare Planning Agreement

HEALTHCARE PLANNING AGREEMENT

Parties and Effective Date

This Healthcare Planning Agreement (the Agreement) is entered into between the undersigned Patient and the Healthcare Planner identified below for the purpose of documenting the Patient's healthcare preferences, advance directives, surrogate decision-maker(s), and related planning services.

Patient Information

Date of Birth:    Gender:    Phone:

Insurance and Records Authorization

I authorize the Healthcare Planner to request and review my medical records as necessary for healthcare planning and preparation of advance directives. Documents may include but are not limited to hospital records, physician notes, and diagnostic results. Authorization expiration date:

Scope of Services

The Healthcare Planner will provide the following services as agreed below. The Planner will act as a facilitator and advisor; the Planner does not provide legal representation unless separately engaged and does not provide medical treatment.

Advance directive drafting and execution assistance
Identification and documentation of surrogate decision-maker(s)
Goals-of-care and values discussion and documentation
Review and summarization of relevant medical records
Coordination with palliative care or hospice resources (non-clinical referral)
Other:

Medical History Summary

Surrogate / Representative

Primary Surrogate Name:    Relationship:
Phone:

Confidentiality, HIPAA and Data Use

The Planner will treat all personal health information as confidential and will comply with applicable privacy laws. The Patient hereby authorizes the Planner to access, use, and disclose health information to the Patient's designated surrogate(s), healthcare providers, and other entities as necessary to carry out the services described in this Agreement.

I acknowledge that I have received notice of privacy practices or have been offered the opportunity to receive such notice.

Fees, Billing and Cancellation

Fee for Services: $    Payment Terms:

Cancellation: If the Patient cancels a scheduled planning session with less than 48 hours' notice, the Planner may charge a cancellation fee not to exceed the full session fee unless otherwise agreed in writing.

Responsibilities and Representations

The Planner represents that services will be provided in a professional manner consistent with applicable standards. The Patient represents that the information provided to the Planner is accurate to the best of the Patient's knowledge and agrees to inform the Planner of material changes to health status or wishes.

Limitation of Liability; Indemnification

To the extent permitted by law, the Planner's liability for any claim arising out of or relating to this Agreement shall be limited to direct damages not to exceed the total fees paid by the Patient to the Planner under this Agreement. The Patient shall indemnify and hold the Planner harmless from claims arising from the Patient's misrepresentation of material facts or failure to disclose material health information.

Termination and Amendment

Either party may terminate this Agreement upon written notice. Termination will not affect obligations incurred prior to termination. This Agreement may be amended only by a written instrument signed by the Patient and the Planner.

Dispute Resolution and Governing Law

Any dispute arising under this Agreement shall be resolved first by good-faith negotiation. If unresolved, the parties agree to binding arbitration. This Agreement is governed by the laws of the state in which the Patient resides at the time of signing.

Acknowledgment and Consent

By signing below, the Patient acknowledges that they have read and understand this Agreement, have had the opportunity to ask questions, and consent to the Planner providing the selected services. The Patient understands that this Agreement is not a substitute for legal advice and that the Patient may consult an attorney for legal document execution if desired.

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