Healthcare Response Agreement

HEALTHCARE RESPONSE AGREEMENT

Effective Date:     Provider Name:     Patient Name:

Purpose and Parties

This Healthcare Response Agreement (the Agreement) sets forth the mutual rights and obligations between the healthcare provider identified above (Provider) and the patient identified above (Patient) regarding Provider's clinical response, triage, treatment coordination and communication services. Provider agrees to respond to Patient requests for urgent and non-urgent clinical assistance in accordance with the terms below.

Patient Information

Insurance Information

Medical History

Scope of Provider Response

Provider will make commercially reasonable efforts to respond to Patient-initiated communications according to the selected methods below. Response may include clinical advice, triage, prescription authorization, in-person appointments or referral to emergency services where clinically indicated.

Response methods (select all that apply):    Phone    Text / Secure Messaging    Telehealth Video    In-Person Visit

Typical response time for urgent matters: . Patient acknowledges that response times vary and that Provider cannot guarantee immediate availability for all requests.

Emergency Protocols

In the event of a life‑threatening emergency, Patient agrees to call local emergency services immediately. Provider is not a substitute for emergency medical care and will not assume responsibility for delays in emergency response beyond Provider's control.

Designated local contact for urgent response if Patient is incapacitated: Name:    Phone:

Consent to Treatment and Communication

By signing this Agreement, Patient consents to Provider delivering clinical evaluation, treatment, advice, prescription management and care coordination as described herein. Patient authorizes Provider to communicate protected health information to other treating clinicians, pharmacies, laboratories and insurers when necessary for treatment, payment or healthcare operations.

Patient hereby grants the following authorizations (check to grant):    Consent to treatment and care coordination    Consent to electronic communication and messaging    Consent to medication management and e-prescribing

Privacy and HIPAA Acknowledgment

Patient acknowledges receipt of Provider's Notice of Privacy Practices and understands that Protected Health Information (PHI) will be used and disclosed as permitted by law for treatment, payment and healthcare operations. Patient may revoke authorizations in writing except to the extent Provider has acted in reliance on this Agreement.

Fees, Billing and Payment

Patient agrees to be responsible for co-payments, co-insurance, deductibles and any charges not covered by insurance. Provider may charge an administrative or telephone triage fee for certain types of response; such fees will be disclosed in advance when practicable.

Billing preferences: Patient authorizes Provider to bill insurance: Yes    Patient agrees to self-pay for uncovered charges: Yes

Limitation of Liability

To the fullest extent permitted by applicable law, Provider's liability for any claim arising from this Agreement or Provider's services is limited to direct damages not to exceed the total amount paid by Patient to Provider for services rendered within the six months preceding the claim. Provider is not responsible for indirect, special, consequential, or punitive damages.

Indemnification

Patient agrees to indemnify and hold Provider harmless from claims arising from Patient's failure to provide accurate medical history or from Patient's misuse of medical advice or prescribed medications, except where such claims arise from Provider's gross negligence or willful misconduct.

Termination

Either party may terminate this Agreement upon written notice. Termination does not relieve Patient of responsibility for charges for services rendered prior to termination. Provider may terminate or suspend response services if Patient engages in abusive or threatening behavior or fails to comply with reasonable clinical directives.

Notices and Communications

Notices required under this Agreement shall be in writing and delivered to the addresses provided in this form or to any updated address provided in writing. Electronic communications are acceptable for routine clinical messages; clinical emergencies require telephone contact or in-person emergency services.

Acknowledgment and Certification

By signing below, Patient certifies that the information provided on this form is true and complete to the best of Patient's knowledge; that Patient has read and understands this Agreement; and that Patient consents to the terms herein. Patient acknowledges the right to withdraw consent in writing, subject to the limitations described above.

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