Healthcare Proposal Contract

HEALTHCARE PROPOSAL CONTRACT

Parties and Effective Date

This Healthcare Proposal Contract (the "Contract") is entered into by and between:

Client Name:    Provider Name:

Effective Date:    Proposal Reference No.:

Scope of Services

Provider shall furnish the clinical services, professional personnel, equipment and supplies described below in accordance with the terms of this Contract and applicable standards of care. Services will be performed at the locations and during the timeframe set forth herein.

Fees, Billing and Payment

Client agrees to pay Provider the fees specified below in exchange for the Services. All fees are due in accordance with the payment terms set forth in this section. Provider shall invoice Client and Client shall remit payment within the stated period absent a timely disputed invoice.

Patient Information

Insurance Information

Medical History

Confidentiality, HIPAA and Privacy

Provider agrees to maintain the confidentiality of patient health information in accordance with applicable law. Provider will implement administrative, physical and technical safeguards to protect Protected Health Information (PHI).

Patient acknowledges receipt of Provider's privacy practices and consents to the use and disclosure of PHI for treatment, payment and healthcare operations as necessary to provide the Services.

I acknowledge receipt of privacy practices and consent to the use and disclosure of my PHI as described above.

Informed Consent; Risks and Withdrawal

Patient has been advised of the nature of the proposed services, reasonably foreseeable risks and benefits, alternatives and potential complications. Patient has the right to ask questions and to withdraw consent at any time prior to or during the provision of Services without waiver of rights, subject to clinical considerations.

Termination, Liability and Indemnification

Either party may terminate this Contract upon thirty (30) days' prior written notice to the other party for convenience. Either party may terminate immediately for material breach. Provider's obligations will be limited to the performance of Services rendered through the effective date of termination. Provider and Client shall indemnify, defend and hold harmless the other party from claims arising from the indemnifying party's negligent acts or omissions, subject to applicable limitations on damages described below.

Compliance and Licensing

Provider represents and warrants that it is duly licensed, certified and authorized under applicable law to perform the Services described herein, and that personnel assigned to perform Services are qualified and hold necessary credentials.

Authorization and Release

By signing below, Patient authorizes Provider to provide the Services described in this Contract. Patient authorizes Provider to communicate with the listed insurance carrier(s) for purposes of billing and payment and to release information necessary for claim adjudication.

Notices

All notices under this Contract shall be in writing and delivered to the addresses below by hand, certified mail, or other commercially reasonable means. Notice is effective upon receipt.

Governing Law and Miscellaneous

This Contract shall be governed by and construed in accordance with the laws of the jurisdiction agreed by the parties below. This Contract constitutes the entire agreement between the parties concerning the subject matter and supersedes prior proposals and agreements. Amendments must be in writing and executed by authorized representatives of both parties.

Signatures

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