Healthcare Service Center Agreement

HEALTHCARE SERVICE CENTER AGREEMENT

This Healthcare Service Center Agreement ("Agreement") is entered into between the parties identified below and is effective on the date indicated as the Effective Date: Effective Date:

PARTIES

Provider Name:    Provider Address:

Patient Name:    Date of Birth:

SCOPE OF SERVICES

Provider shall furnish healthcare services as described below. Services to be provided (include tests, treatments, therapies, counseling, diagnostics, and other services):

Anticipated start date:    Anticipated end/completion date:

FEES, PAYMENT, AND INSURANCE

Patient acknowledges responsibility for payment of fees for services rendered by Provider in accordance with Provider's fee schedule. Estimated charges for the services described above:

Patient hereby authorizes Provider to submit claims to Patient's insurance and to accept assignment of benefits to Provider where permitted. Patient remains ultimately responsible for charges not covered by insurance, including co-payments, deductibles, and non-covered services.

PATIENT MEDICAL HISTORY

CONSENT FOR TREATMENT AND AUTHORIZATIONS

Patient authorizes Provider and Provider's agents and staff to perform the services described in this Agreement. Patient acknowledges that Provider has explained the nature, purpose, potential benefits, and material risks of the proposed services and has had the opportunity to ask questions. Patient understands that no guarantee or promise of cure or specific outcome has been made.

Patient acknowledges the right to withdraw consent at any time, except to the extent that Provider has already taken action in reliance on this consent. Withdrawal of consent will not affect actions already taken pursuant to this Agreement.

Authorization to release medical records and exchange information with other healthcare providers or insurers in furtherance of care or billing: Patient grants Provider the right to disclose protected health information as necessary for treatment, payment, and healthcare operations in accordance with applicable law. This authorization expires on:

HIPAA PRIVACY ACKNOWLEDGEMENT

Patient acknowledges receipt of the Provider's Notice of Privacy Practices describing how medical information may be used and disclosed and how Patient may obtain access to this information. Patient understands Provider will use and protect Patient's health information as required by law.

CANCELLATION, NO-SHOW, AND TERMINATION

Patient agrees to provide timely notice of cancellation as required by Provider's policy. Provider may assess cancellation or no-show fees in accordance with its standard policies. Either party may terminate this Agreement for cause upon written notice to the other party; Provider may terminate where continued treatment would pose a risk to Patient or staff.

CONFIDENTIALITY, INDEMNITY, AND LIMITATION OF LIABILITY

Provider will maintain confidentiality of Patient information in accordance with applicable law. Patient agrees to indemnify and hold Provider harmless from liabilities arising from Patient's failure to disclose material facts or comply with instructions. To the fullest extent permitted by law, Provider's liability for claims arising out of this Agreement is limited to direct damages not to exceed the fees paid by Patient for the service at issue; Provider shall not be liable for consequential, incidental, or punitive damages.

DISPUTE RESOLUTION AND GOVERNING LAW

The parties shall attempt to resolve disputes in good faith by negotiation. If unresolved, disputes shall be submitted to mediation or, if agreed upon, binding arbitration. This Agreement shall be governed by the laws of the jurisdiction in which Provider's principal place of business is located, without regard to conflict of law principles.

COMMUNICATION CONSENT

Patient consents to communications from Provider for appointment reminders, billing, and clinical information. Patient may withdraw consent for particular methods by notifying Provider.

REPRESENTATIONS AND WARRANTIES

Each party represents and warrants that it has authority to enter into this Agreement and that the information provided herein is true and complete to the best of its knowledge. Patient affirms that Patient has disclosed all known medical conditions, medications, and allergies that could reasonably affect the provision of services.

ADDITIONAL TERMS

Any amendments to this Agreement must be made in writing and signed by both parties. If any provision is found invalid or unenforceable, the remaining provisions will remain in full force and effect.

Sign Now