Healthcare Renewal Proposal

Healthcare Renewal Proposal

This Healthcare Renewal Proposal (Proposal) documents the Provider's proposed terms to renew and continue healthcare services for the identified patient. The Proposal describes proposed services, estimated fees, billing and authorization terms, privacy acknowledgments, and the patient's acceptance requirements.

Patient Information

Patient Name:

Day: Month: Year:

Male   Female   Other / Prefer not to say

Insurance Information

Medical History (Current)

Proposed Renewal Details

Description of Proposed Services:

Proposed Effective Date:

Billing frequency: Monthly   Per service   Other

Risks, Benefits and Alternatives

The proposed services are intended to achieve the outcomes described in the service plan. Benefits may include improved clinical status, symptom reduction, or functional gains. Risks include but are not limited to treatment-related adverse events, incomplete response, or unforeseen complications. Reasonable alternatives and the option to decline renewal are available. The patient retains the right to withdraw consent for services at any time in accordance with the Provider's termination policy.

Financial Responsibility and Billing Terms

By accepting this Proposal the patient or responsible party agrees to pay charges not covered by insurance, including copayments, deductibles, and services denied as not medically necessary. Provider will bill the insurer as a courtesy; however final responsibility for payment remains with the patient or guarantor. Providers may suspend services for nonpayment in accordance with applicable law and notice requirements.

Financial responsibility accepted: I accept financial responsibility as set forth above.

Authorization to Obtain and Release Medical Information

I authorize the Provider to obtain and disclose medical information as reasonably necessary to evaluate eligibility for continued care, to coordinate treatment, to process claims with insurance carriers, and to obtain payment. This authorization is voluntary and may be revoked in writing, except to the extent that the Provider has already acted in reliance on it.

Authorization Expiration:

Release scope: Treatment information   Billing / Payment information   Other (specify in notes)

Privacy Acknowledgment (HIPAA)

I acknowledge that I have received a copy of the Provider's Notice of Privacy Practices describing how protected health information may be used and disclosed and my rights with respect to that information. I understand that the Notice explains how to request restrictions, confidential communications, and access to my medical record.

Acknowledgment: I acknowledge receipt of the Notice of Privacy Practices.

Terms and Conditions

1. Termination: Either party may terminate services upon written notice in accordance with the Provider's termination policy. Outstanding charges for services rendered through the effective termination date remain due and payable.

2. Limitation of Liability: To the fullest extent permitted by law, Provider's liability for any claim arising from services provided is limited to direct damages not exceeding the amount of fees paid under this Proposal for the period in which the claim arose.

3. Amendment: Any amendment to this Proposal must be in writing and signed by the patient or authorized representative and an authorized representative of the Provider where required by law or Provider policy.

4. Governing Law: This Proposal is to be interpreted under applicable local and state laws governing patient care and contractual obligations.

Patient Acknowledgment and Acceptance

By signing below I certify that I am the patient or the patient's authorized representative. I have read and understand this Proposal, including the scope of proposed services, associated fees, privacy practices, and authorization to obtain and disclose medical information. I accept the proposed renewal and authorize the Provider to proceed as described.

Acceptance: I accept the terms of this Healthcare Renewal Proposal.

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