Healthcare Service Terms

HEALTHCARE SERVICE TERMS

Parties and Effective Date

This Healthcare Service Terms Agreement (the "Agreement") is entered into between Provider Name: and Patient Name: . Effective Date:

Patient Information

Male Female Other / Prefer not to state

Insurance and Billing

Insurance Provider:

Patient acknowledges responsibility for co-payments, deductibles, non-covered services, and timely payment for services not paid by insurance. Provider retains the right to bill patient directly for services rendered when insurance coverage is denied or incomplete.

Scope of Services

Provider will furnish healthcare services as medically indicated and agreed between Provider and Patient. Description of planned services, procedures or treatment goals:

Patient Responsibilities

Patient agrees to (i) provide accurate medical history and medication lists; (ii) follow agreed treatment plans and instructions; (iii) notify Provider of changes in health or insurance; and (iv) attend scheduled appointments or provide timely cancellation notice.

Consent to Treatment and Risks

By signing below, Patient gives informed consent for the provision of medical care and related services described above. Patient acknowledges that Provider has explained the nature, purpose, anticipated benefits, material risks, and reasonable alternatives of the proposed care. Patient further acknowledges the right to ask questions and to withdraw consent at any time, subject to reasonable notice and any necessity for emergency care.

Privacy, Use and Disclosure of Health Information (HIPAA Acknowledgment)

Patient acknowledges receipt of Provider’s privacy practices describing the use and disclosure of protected health information for treatment, payment and healthcare operations. Patient authorizes Provider to use and disclose health information as necessary for treatment, billing, and coordination of care unless otherwise restricted in writing by Patient.

Acknowledgment of Receipt of Privacy Practices: I acknowledge receipt of privacy practices

Fees, Payment and Collections

Patient is responsible for payment of all charges for services rendered. Provider will bill insurance as a courtesy when authorized. Patient is responsible for any portion not paid by insurance including co-payments, coinsurance, deductibles and services excluded from coverage. For unpaid balances, Provider may engage collections and charge reasonable fees for collection and legal costs.

Limitation of Liability; Indemnification

To the fullest extent permitted by law, Provider’s liability for any claim arising out of the services provided is limited to direct damages and shall not exceed the total amount paid by Patient for the specific services at issue. Patient agrees to indemnify and hold Provider harmless from claims arising from Patient’s failure to follow medical advice or from inaccurate information provided by Patient.

Termination and Amendments

Either party may terminate this Agreement upon written notice. Termination does not relieve Patient of financial obligations for services rendered prior to termination. Provider may amend these terms with notice to Patient; continued receipt of services following reasonable notice constitutes Patient’s acceptance of amended terms.

Dispute Resolution

The parties agree to attempt good faith negotiation of disputes arising under this Agreement. If unresolved, disputes shall be resolved by binding arbitration in the jurisdiction where Provider maintains its principal practice, pursuant to the rules of the chosen arbitration forum. Judgment on the award rendered by the arbitrator may be entered in any court having jurisdiction.

Notices

All notices required under this Agreement shall be in writing and delivered to the addresses provided by the parties in this form. Notice is effective on the date of personal delivery or three days after deposit in the U.S. mail, postage prepaid.

Emergency Care

In the event of an emergency, Provider will take reasonable steps to provide or arrange emergency care. Patient authorizes Provider to seek emergency services as necessary and understands such services may be billed separately.

Acknowledgment and Acceptance

By signing below, Patient affirms that the information provided is true and accurate to the best of Patient’s knowledge, that Patient has had an opportunity to ask questions, and that Patient accepts and agrees to be bound by the terms set forth herein.

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