Healthcare Pulmo Services Agreement

HEALTHCARE PULMO SERVICES AGREEMENT

Parties and Effective Date

Provider Name:

Patient Name:    Date of Birth:

Gender: Male Female Other

Scope of Services

Provider agrees to furnish pulmonary services as indicated by clinical evaluation, which may include diagnostic testing, spirometry, arterial blood gas analysis, oxygen assessment, therapeutic respiratory procedures, education and home equipment evaluation. Services to be provided (describe):

Consent to Treatment, Risks and Benefits

The patient consents to the performance of the above pulmonary services and related procedures. Provider has explained the nature of the proposed services, expected benefits, material risks and reasonable alternatives, including the risks of refusing treatment. Patient acknowledges that no guarantee of outcome has been made.

I acknowledge that I have been informed of the risks and benefits and consent to treatment: I agree

Insurance, Billing, and Financial Responsibility

Patient is responsible for payment of services rendered and for obtaining any required prior authorizations from insurer. Provider will bill the listed insurer as a courtesy if assignments are authorized below.

Assignment of Benefits: I authorize payment of benefits to Provider and assignment of insurance payments to Provider.

Medical History

Smoking History:

HIPAA Authorization and Release of Records

Patient authorizes Provider to use and disclose protected health information as necessary for treatment, payment and healthcare operations. Patient further authorizes release of medical records and related information to referring providers, insurance carriers and their agents as necessary for billing and continuity of care.

Authorization for Release of Records Expires:

I authorize release of records as described above: I agree

Patient Responsibilities; Cancellation; No-Show

Patient agrees to arrive for scheduled appointments on time, to notify Provider within the specified policy period for cancellations, and to be responsible for fees associated with missed appointments or late cancellations as outlined by Provider policy. Insurance may not cover missed-appointment fees; patient remains responsible.

Patient acknowledges provider cancellation/no-show policy: I acknowledge

Liability, Indemnification and Emergency Care

Provider will exercise reasonable care in performing services. To the extent permitted by law, Provider's liability for any claim arising from the services provided is limited to direct damages not to exceed the amount paid by or on behalf of the patient for the services at issue. Patient agrees to indemnify and hold Provider harmless from claims arising from patient's negligence or failure to follow instructions.

In the event of a medical emergency, Provider will provide or arrange for emergency treatment and will notify the patient or designated emergency contact as soon as practicable.

Termination and Amendment

Either party may terminate this Agreement for any reason upon written notice to the other. Termination does not relieve the patient of responsibility for payment for services rendered prior to termination. This Agreement may be amended only by written instrument signed by both parties.

Governing Law and Dispute Resolution

This Agreement is governed by the laws of the state in which Provider maintains its principal place of business. Parties will attempt to resolve disputes informally before pursuing formal legal remedies. If litigation arises, the prevailing party is entitled to recover reasonable attorneys' fees and costs to the extent permitted by law.

Acknowledgment and Certification

By signing below, I certify that the information provided is true and complete to the best of my knowledge; I have read, understand and accept the terms of this Agreement; I consent to the described pulmonary services; and I authorize Provider to bill my insurance and to release information as necessary for treatment and payment.

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