Healthcare Signed Contract

HEALTHCARE SERVICES AGREEMENT

Parties and Effective Date

This Healthcare Services Agreement (the Agreement) is entered into by and between Provider Name: and Patient Name: . Effective Date: .

Patient Information

Provider Information

Insurance Information

Medical History

Scope of Services

Provider shall provide the following professional services to Patient in accordance with accepted standards of care. Description of services:

Risks, Benefits and Alternatives

Provider has explained to Patient the nature of the proposed services, the expected benefits, material risks and potential complications, and reasonable alternatives including no treatment. Patient acknowledges that no guarantee of results has been made.

Payment, Billing and Assignment

Patient agrees to pay Provider for services rendered in accordance with Provider's fee schedule. Patient is responsible for co-payments, deductibles, non-covered services and amounts in excess of insurer allowances. Provider may bill Patient's insurance on Patient's behalf where permitted.

Privacy, HIPAA and Release of Information

Provider will maintain the privacy of Patient's protected health information (PHI) in accordance with applicable law. Patient acknowledges receipt of Provider's Notice of Privacy Practices and consents to uses and disclosures necessary for treatment, payment and health care operations.

Consent to Treatment and Limitation of Liability

By signing below, Patient consents to the provision of services described in this Agreement. Patient understands the inherent risks and agrees that Provider will not be liable for any adverse outcome unless caused by Provider's gross negligence or willful misconduct. Patient releases Provider from liability to the extent permitted by law.

Term, Termination and Remedies

This Agreement remains in effect until services are completed, or terminated by either party upon written notice. Termination shall not relieve Patient of financial obligations for services rendered prior to termination. Disputes shall be resolved by the remedies available at law and equity; if required, the parties may pursue dispute resolution as provided below.

Governing Law and Notices

This Agreement is governed by the laws of the state in which Provider maintains its principal place of business. Notices required under this Agreement must be in writing and delivered to the addresses provided in this form.

Miscellaneous Provisions

This Agreement constitutes the entire agreement between the parties with respect to its subject matter. Any amendment must be in writing and signed by both parties. If any provision is held invalid, the remaining provisions remain in full force and effect.

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