Healthcare Services Draft

HEALTHCARE SERVICES DRAFT

Provider and Patient Identification

Agreement Between Provider: and Patient Name: . Effective Date:

Patient Contact Information

Emergency Contact

Insurance Information

Medical History

Scope of Services

Provider shall render the healthcare services described below to Patient in accordance with generally accepted standards of practice and applicable law. Description of services:

Fees, Billing and Insurance Assignment

Patient is financially responsible for fees not covered by insurance, co-payments, deductibles, and any services deemed noncovered. Estimated fees: .

Assignment of Benefits: Patient hereby assigns to Provider the right to submit claims and receive payments from Patient's insurer for services rendered and to obtain medical information necessary to process claims. Patient authorizes Provider to release medical information to insurers as needed for claims processing and payment.

Consent to Treatment and Acknowledgment of Risks

Patient acknowledges that Provider has explained the nature, purpose, expected benefits, and material risks of the proposed treatments and alternatives. Patient authorizes Provider and its staff to perform the described treatments and related care. Patient understands that outcomes cannot be guaranteed and that complications may occur.

HIPAA Authorization and Privacy Acknowledgment

Patient acknowledges receipt of Provider's Notice of Privacy Practices describing uses and disclosures of protected health information. Patient authorizes Provider to use and disclose protected health information for treatment, payment, and healthcare operations, and to communicate with Patient by telephone, mail, and electronic means unless Patient specifies otherwise in writing.

Revocation: Patient may revoke this authorization at any time by delivering a written revocation to Provider, except to the extent Provider has already acted in reliance on this authorization.

Termination; Default

Either party may terminate this Agreement with written notice to the other if material breach is not cured within a reasonable period. Provider may suspend services for nonpayment. Patient remains responsible for fees for services rendered through the effective date of termination and any applicable collection costs.

Indemnification; Limitation of Liability; Miscellaneous

Patient agrees to indemnify and hold Provider harmless from claims arising from Patient's misuse of treatment, failure to follow instructions, or inaccurate information provided. Except for willful misconduct or gross negligence, Provider's liability for any claim arising from services is limited to direct damages not to exceed the total fees paid by Patient for the contested services. If any provision is held invalid, remaining provisions remain effective. This Agreement constitutes the entire agreement between the parties regarding the services described herein and may be modified only by a written instrument signed by both parties.

Acknowledgment and Patient Certification

By signing below, Patient certifies that the information contained in this document is accurate to the best of Patient's knowledge, that Patient has had the opportunity to ask questions, and that Patient consents to the provision of services and the use and disclosure of protected health information as described above.

Sign Now