Healthcare Program Terms

HEALTHCARE PROGRAM TERMS

Program and Parties

Program Name:

Provider Name:

Client Name:

Patient Information

Insurance Information

Medical History

Program Description and Terms

Description of Services: The program will provide the services described below. Services may include scheduled clinical assessments, remote monitoring, care coordination, patient education, and telehealth consultations. Specific services provided to the participant will be:

Fees, Billing and Payment Authorization

Fees: I understand the fees associated with participation, including any co-pay, deductible, or program fee. Fees will be charged as follows:

Billing Authorization: By checking the box below, I authorize billing to my insurance and/or direct billing to my payment method for program services and agree to provide accurate insurance and payment information.

I authorize billing for program services and attest that the insurance information provided is accurate.

Consent to Participate, Risks and Benefits

Consent: I consent to participate in the program described above. I have been informed of the nature and scope of services, potential benefits, and foreseeable risks, which may include, but are not limited to, limitations of remote monitoring, communication delays, potential for incomplete data transmission, and privacy risks associated with electronic communications.

Voluntary Participation and Withdrawal: Participation is voluntary. I may withdraw from the program at any time by providing written notice to the Provider. Withdrawal will not affect my right to other medical care.

I have read and understand the risks and benefits and consent to participate in the program.

Privacy, Data Use, and Information Sharing

HIPAA and Confidentiality: The Provider will protect health information in accordance with applicable privacy laws. To facilitate care coordination, I authorize the Provider to use and disclose my protected health information to other treating clinicians, care managers, and entities directly involved in program activities.

Third-Party Services and Technology: I understand the program may use third-party platforms or devices for monitoring and communication. I authorize the exchange of necessary health information with such vendors when required to deliver program services.

I authorize release and exchange of my health information as described above.

Termination, Amendment and Liability

Termination: Either party may terminate participation upon written notice. Provider may terminate participation if continuation poses a risk to patient safety or violates program rules.

Amendments: Provider may amend program procedures or policies; material changes will be communicated to participants in writing. Continued participation after notice constitutes acceptance of amendments.

Limitation of Liability: Except as prohibited by law, Provider's liability for any claim arising from participation is limited to direct damages not to exceed amounts actually paid by or on behalf of the participant for the program services giving rise to the claim. Provider is not liable for indirect, consequential, or punitive damages.

Acknowledgment and Certifications

By signing below I certify that the information I have provided on this form is true and accurate to the best of my knowledge. I understand the terms of participation, the billing arrangements, and my rights to withdraw. I authorize Provider to obtain, use, and disclose my health information as necessary for program participation and care coordination.

I certify that the information provided is accurate and that I have read and understand these Healthcare Program Terms.

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