Healthcare Room and Board Agreement

HEALTHCARE ROOM AND BOARD AGREEMENT

Parties and Facility Information

Facility Name:

Patient Information

Date of Birth:    Gender: Male Female Other

Primary Phone:    Email:

Emergency Contact

Relationship:    Phone:

Insurance and Payment

Policy / ID Number:    Group Number:

Payment Responsibility (select all that apply):
Private Pay Medicare Medicaid Other

Room Assignment and Services

Assigned Room/Bed Number:    Unit/Wing:

Admission Date:    Expected Discharge Date:

Skilled Nursing Assisted Living Long-Term Care Respite Care

Rates, Billing, and Payments

Room & Board Rate:    Billing Frequency:

Patient or Responsible Party agrees to pay all charges not covered by third-party payers. The facility may bill the patient directly for co-payments, deductibles, and non-covered services. Charges are due within the facility's standard payment terms; delinquent accounts may incur late fees, interest, and actions for collection, including costs of collection and reasonable attorney fees.

Medical Information and History

Consent, Authorizations, and Acknowledgments

By signing this Agreement the patient or authorized representative authorizes the facility to provide room, board and routine care as described herein and to obtain or provide such emergency medical care and nursing services as the facility in its professional judgment deems necessary.

Patient consents to emergency medical treatment and transportation as necessary.

Patient acknowledges receipt of the facility's Notice of Privacy Practices and authorizes the facility to use and disclose protected health information for treatment, payment, and healthcare operations consistent with applicable law.

The patient authorizes the facility to disclose health information to the following persons for the purposes of care coordination, billing, and notification:

Termination, Transfer, and Discharge

This Agreement may be terminated by the patient upon written notice in accordance with facility policy. The facility may terminate or transfer the patient for medical reasons, non-payment, danger to self/others, or material breach of facility rules. The facility shall provide reasonable notice and discharge planning consistent with applicable law. The patient agrees to pay for services rendered through the date of discharge.

Liability, Indemnity, and Governing Law

The facility will exercise reasonable care in providing room, board and health services. The patient releases the facility from liability for loss or damage to personal property except to the extent caused by the facility's gross negligence or willful misconduct. The patient agrees to indemnify and hold the facility harmless from claims arising from the patient's acts or omissions. This Agreement shall be governed by the laws of the state in which the facility is located.

Miscellaneous Provisions

Amendments to this Agreement must be in writing and signed by an authorized facility representative. If any provision is found unenforceable, the remaining provisions remain in full force and effect. The headings are for convenience and do not affect interpretation.

Acknowledgment and Certification

By signing below, the patient or authorized representative certifies that the information provided is true and complete to the best of their knowledge, that they have had the opportunity to ask questions regarding the services, rates, and facility policies, and that they accept the terms of this Room and Board Agreement.

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