Can this exhibit be signed electronically?

Yes. Electronic signatures are enforceable under the federal ESIGN Act (15 U.S.C. §7001) and UETA where adopted; ensure any consumer disclosures required by ESIGN are provided for consumer‑facing transactions.

Is a Business Associate Agreement required?

Yes when the exhibit permits exchange of protected health information; execute a BAA to satisfy HIPAA obligations and document permitted uses and safeguards.

Who may sign for a provider organization?

An authorized representative with authority to bind the entity should sign; document the signer's title and authority in the exhibit or an attached signature authority schedule.

Are witnesses or notarization needed?

Most exhibits do not require witnesses, but state rules may require notarization for certain attachments; check state notary and deed rules for jurisdictional exceptions.

What happens if a signature is contested?

Retain the full audit trail (timestamps, IP, authentication method) and any consent disclosure; these records support attribution and rebut repudiation claims under ESIGN/UETA.

How do I revoke or amend an exhibit?

Follow amendment or termination provisions in the primary agreement; execute a written amendment or termination exhibit signed by authorized parties and preserve prior versions for audit.

Electronic Signature
Templates
Healthcare
Healthcare Services Exhibit

Healthcare Services Exhibit

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

HEALTHCARE SERVICES EXHIBIT

This Healthcare Services Exhibit (the Exhibit) sets forth the specific scope, schedule, compensation and operational requirements for services to be provided under the underlying agreement between the parties. Service Provider: Client/Facility: Effective Date:

1. Patient Information

Patient Full Name

Date of Birth:

Gender:

Medical Record # :

Primary Address

Phone:

Emergency Contact:

Emergency Contact Phone:

2. Insurance & Billing

Insurance Provider

Policy Number:

Group Number:

Subscriber Name:

Billing Responsibility: . Claims will be submitted in accordance with the agreed billing procedures and payer rules; Client remains responsible for unpaid balances.

3. Service Description & Schedule

Services to be Provided (Detailed description)

Service Location:

Frequency:

Service Start Date:

Service End Date:

Renewal Terms:

4. Clinical Information & Precautions

Current Medications Allergies / Adverse Reactions Prior Surgeries / Significant Medical History Chronic Conditions / Special Care Needs

5. Staffing, Training & Equipment

Provider shall furnish personnel who are licensed, certified and trained as required by applicable law. Minimum qualifications for assigned staff:

Required Equipment or Supplies

Special Service Options (check all that apply) Telehealth Home Visit Respite Care Medication Administration

6. Compensation & Invoicing

Rate Schedule: Provider shall be paid according to the rates set forth below. Unit rate: per .

Billing Frequency: . Payment terms: Net days from invoice date.

7. Compliance, Privacy & Records

Provider and Client shall comply with all applicable laws and regulations governing the provision of healthcare services, including privacy protections. Provider agrees to maintain administrative, technical and physical safeguards to protect protected health information consistent with applicable law.

HIPAA / Privacy Acknowledgment

By signing this Exhibit, the parties acknowledge receipt of the applicable privacy notices and agree that Provider may use and disclose patient health information as required for treatment, payment and healthcare operations. Patient authorization for additional disclosures is below.

Authorization to Release Medical Information

Authorization Expiration Date: . Authorization may be revoked in writing, subject to prior disclosures made in reliance on the authorization.

8. Liability, Insurance & Indemnification

Provider shall maintain professional liability insurance and general liability insurance at levels sufficient for the services provided. Provider shall furnish certificates of insurance upon request. Each party shall indemnify the other for losses resulting from its breach, willful misconduct, or negligent acts, subject to the limitations set forth in the underlying agreement.

Insurance Notes (limits, carriers, if required)

9. Termination & Modification

Either party may terminate the services described in this Exhibit for material breach if the breach is not cured within the time period specified in the underlying agreement. Termination for convenience requires days' prior written notice.

Modifications to scope, schedule, rates or staffing shall be made only by a written amendment signed by authorized representatives of both parties.

10. Notices

Provider Notice Address Client Notice Address

11. Certifications

Each party certifies that the information contained in this Exhibit is true and correct to the best of its knowledge, that it has authority to enter into this Exhibit, and that it will perform its obligations in accordance with applicable law and the underlying agreement.

Service Provider Printed Name:

By:

Date:

Client / Facility Printed Name:

By:

Date:

What the Healthcare Services Exhibit Is

A Healthcare Services Exhibit is a contract attachment that documents the scope, responsibilities, payment terms, privacy obligations, and operational details for clinical or non‑clinical services provided to a health care organization or its patients. It supplements a primary agreement by listing service descriptions, deliverables, billing codes or rates, credentialing requirements, data‑sharing permissions, and any HIPAA‑related safeguards. The exhibit creates a focused record for operational teams, compliance reviewers, and payers, and it is commonly used in provider contracts, vendor services agreements, and managed care attachments.

Why a Clear Exhibit Matters

A well‑drafted Healthcare Services Exhibit reduces ambiguity about services, billing, and data handling, supports regulatory compliance (including HIPAA), and makes contract administration and auditability simpler for both providers and payers.

Who typically prepares and relies on this exhibit

Each stakeholder uses the exhibit for different tasks — operational execution, compliance oversight, and payment processing — so clarity and consistent data fields are essential.

Healthcare administrators and contracting teams responsible for vendor relationships and operational oversight.
Clinical leaders and credentialing staff who verify provider qualifications and scope of care.
Finance, billing, and revenue cycle teams who use the exhibit for fee schedules and payer instructions.

Step-by-step: complete, sign, and record the exhibit

Follow these sequential steps to prepare, obtain approvals, and finalize the Healthcare Services Exhibit.

01

Draft: Populate scope, codes, fees, and data permissions accurately.
02

Internal Review: Send to legal, compliance, clinical, and billing for sign‑off.
03

Obtain Signatures: Collect authorized signatures using an audit‑capable eSignature solution.
04

Store and Distribute: Save executed copy to contract repository and share with operations.

Typical digital configuration for eSubmission and routing

Suggested field and routing settings for an electronic exhibit workflow to support audit, access control, and retention.

Field	Configuration
Authentication	Email plus optional SMS or ID verification for higher assurance
Signature Type	Legal electronic signature; use PKI only if required by regulation
Conditional Fields	Show billing details only when service type equals 'billable'
Retention Flag	Apply HIPAA retention policy tag for PHI-containing exhibits

Technical considerations for digital signing and storage

Match platform capabilities to compliance needs such as HIPAA, 21 CFR Part 11, and your internal retention and audit requirements.

File Formats: PDF, DOCX, and fillable forms supported
Integrations: Connects with EHR, NetSuite, Salesforce, and cloud storage
Authentication: Supports email, SMS, and advanced signer verification

How electronic submission typically works

An efficient eSubmission workflow reduces manual handling while preserving evidentiary logs and access controls.

Upload: Sender uploads exhibit and supporting attachments
Place Fields: Add signature, date, and conditional billing fields
Send: Dispatch by secure link or email to signers
Record: System captures audit trail and stores executed copy

Key timing and processing expectations

Typical deadlines and time expectations to align contracting, credentialing, and billing workflows.

Effective Date Entry:

Enter the agreed effective date before routing for signature

Credentialing Lead Time:

Allow 30–90 days for provider credentialing and privileging

Billing Activation:

Submit payor enrollment within 30 days of execution

Claims Submission:

Adhere to payer claim filing deadlines, typically 90–365 days

Audit Access:

Provide executed exhibit within 5 business days when requested

Typical processing milestones after finalization

A concise milestone sequence helps teams track status from execution to operational start.

01

Final Review

Legal and compliance confirm final terms and HIPAA clauses

02

Signatures Collected

All authorized parties execute the exhibit electronically

03

Operational Handoff

Billing and clinical teams receive exhibit and implement processes

04

Monitoring

Conduct periodic compliance checks and performance reviews

Common preparation errors to avoid

Using vague service descriptions that omit codes or measurable deliverables, which leads to billing disputes and service disagreements.
Failing to specify data sharing or PHI handling rules, increasing the risk of unauthorized disclosures and HIPAA violations.
Mismatched party names or missing tax IDs that delay payment or trigger backup withholding under IRS rules.
Skipping internal approvals from clinical, legal, or billing teams, which increases operational friction and audit risk.

Security and compliance essentials to include

Encryption: AES-256 at rest

Transport Security: TLS 1.2/1.3 in transit

HIPAA BAA: Required when PHI is exchanged

Audit Trail: Timestamps, IP, and action log

Authentication: Email, SMS, or advanced methods

Regulatory Standards: ESIGN, UETA, 21 CFR Part 11

Consequences of defects or noncompliance

Contract Dispute: Enforceability challenged

Payment Delays: Claims rejected or delayed

HIPAA Penalties: Civil and criminal fines possible

Regulatory Action: State agency enforcement risk

Tax Penalties: Backup withholding or IRS penalties

Operational Disruption: Credentialing delays and service gaps

Real examples of exhibits in practice

Short examples illustrate typical benefits and implementation notes from real users.

Optica Ventures

The team standardized exhibits across service lines to reduce onboarding time by clarifying scope and rates.

They used code lists and templates for consistency.
The result was fewer billing disputes and faster operational handoffs between finance and clinical operations.

Fertility Centers of Illinois

The organization added detailed PHI handling and a BAA to all exhibits to protect patient data.

The exhibit required provider attestation and credentialing attachments.
This approach improved audit readiness and clarified responsibilities for subcontracted clinical staff.

Practical tips for accurate, efficient exhibits

Adopt these practices to reduce cycle time and maintain compliance across contracting and operations.

Standardize language

Use approved templates and code lists to prevent variations that cause billing or scope disputes.

Validate names and IDs

Confirm legal entity names and tax IDs to avoid payment or IRS backup withholding issues.

Include HIPAA language

Add a BAA and specific PHI handling instructions when applicable to meet regulatory obligations.

Preserve the audit trail

Store executed exhibits with a timestamped audit record and access logs for compliance reviews.

eSignature vendors and pricing considerations

A concise vendor comparison focused on starting price, trial availability, bulk send, audit capability, HIPAA support, and envelope limitations to inform procurement assessments.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies by plan	Varies by plan	Varies by plan	Varies by plan
Bulk Send	Yes (Business Premium)	Yes	Yes	Yes	Varies
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No envelope cap	100 envelopes/user/year	Varies by plan	Varies by plan	Varies by plan

Frequently asked questions and practical answers

Common questions about use, signing, and compliance for the Healthcare Services Exhibit, with clear, practical answers.

Need help? Contact support

Can this exhibit be signed electronically?
Yes. Electronic signatures are enforceable under the federal ESIGN Act (15 U.S.C. §7001) and UETA where adopted; ensure any consumer disclosures required by ESIGN are provided for consumer‑facing transactions.
Is a Business Associate Agreement required?
Yes when the exhibit permits exchange of protected health information; execute a BAA to satisfy HIPAA obligations and document permitted uses and safeguards.
Who may sign for a provider organization?
An authorized representative with authority to bind the entity should sign; document the signer's title and authority in the exhibit or an attached signature authority schedule.
Are witnesses or notarization needed?
Most exhibits do not require witnesses, but state rules may require notarization for certain attachments; check state notary and deed rules for jurisdictional exceptions.
What happens if a signature is contested?
Retain the full audit trail (timestamps, IP, authentication method) and any consent disclosure; these records support attribution and rebut repudiation claims under ESIGN/UETA.
How do I revoke or amend an exhibit?
Follow amendment or termination provisions in the primary agreement; execute a written amendment or termination exhibit signed by authorized parties and preserve prior versions for audit.

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