Healthcare Subscription Terms

HEALTHCARE SUBSCRIPTION TERMS

Provider Name:     Subscriber (Patient) Name:

Effective Date:

1. Definitions and Services

1.1 Definitions. "Subscription" means the recurring membership or service package selected by the Subscriber that grants access to the Services described below. "Services" means the clinical, administrative, telehealth, care coordination, or other healthcare services provided by the Provider pursuant to this Agreement.

1.2 Services Provided. The Provider will deliver the Services as described in the selected plan. Subscriber selects plan: Basic (limited visits and messaging) Standard (expanded access, standard consultations) Premium (priority access, extended services)

2. Patient Information

3. Insurance and Medical History

4. Fees, Billing and Payment Authorization

Subscription Fee Amount: $     Billing Frequency: Monthly Quarterly Annual

Payment Method: Credit Card ACH / Bank Transfer Invoice

By checking the box below, Subscriber authorizes Provider to charge the Subscription Fee in accordance with the selected billing frequency and to automatically renew the Subscription unless terminated in accordance with Section 6. I authorize automatic recurring charges.

5. Term, Renewal and Cancellation

Term Commencement:     Initial Term Length:

Renewal: Unless Subscriber provides written notice of non-renewal at least days prior to the end of the then-current term, this Subscription will automatically renew for successive terms equal to the expiring term.

Cancellation and Refunds: Subscriber may cancel by providing written notice to Provider. Refunds, if any, will be issued in Provider's sole discretion and subject to the refund policy disclosed at enrollment. Provider may terminate for non-payment or material breach after providing notice and a reasonable cure period.

6. Patient Responsibilities and Conditions of Service

Subscriber agrees to provide accurate and complete medical, insurance, and contact information, to comply with reasonable clinical instructions, and to keep scheduled appointments. Subscriber acknowledges that certain services may be limited by clinical judgment, availability, or insurance coverage and that the Subscription does not guarantee specific outcomes.

7. Privacy, HIPAA Authorization and Electronic Communications

Subscriber acknowledges receipt of Provider's Notice of Privacy Practices and consents to electronic communications for scheduling, billing, and clinical communications where permitted. Subscriber authorizes Provider to use and disclose protected health information as necessary for treatment, payment, and healthcare operations.

Electronic Consent: I consent to receive electronic notices, invoices, and clinical communications at the email and phone provided above.

8. Liability, Indemnification and Dispute Resolution

Disclaimer of Warranties: Provider provides Services in accordance with applicable professional standards. Except as explicitly set forth in this Agreement, Provider disclaims all warranties, express or implied, including merchantability and fitness for a particular purpose.

Limitation of Liability: To the maximum extent permitted by law, Provider's aggregate liability arising from or related to this Agreement shall not exceed the total Subscription fees paid by Subscriber in the six (6) months prior to the claim. In no event shall Provider be liable for incidental, consequential, punitive, or special damages.

Indemnification: Subscriber shall indemnify and hold Provider and its affiliates harmless from any claims, damages, or liabilities arising from Subscriber's breach of this Agreement, willful misconduct, or negligent provision of inaccurate information.

9. Governing Law, Notices and Miscellaneous

Governing Law: This Agreement is governed by the laws of the state indicated by the Provider's principal address. Any dispute arising under this Agreement shall be resolved in the courts of that jurisdiction, subject to mandatory arbitration clauses only where explicitly agreed in writing.

Assignment and Amendment: Subscriber may not assign this Agreement without Provider's prior written consent. Provider may amend terms upon thirty (30) days' advance notice; continued payment after the effective date of amendment constitutes acceptance.

Entire Agreement and Severability: This Agreement, together with any enrollment documents and the Notice of Privacy Practices, constitutes the entire agreement between the parties. If any provision is held invalid, the remainder shall remain in effect.

10. Acknowledgements and Authorizations

By signing below, Subscriber acknowledges that they have read, understand, and agree to be bound by these Healthcare Subscription Terms, that they have provided accurate medical and insurance information to the best of their knowledge, and that they authorize Provider to charge the payment method on file in accordance with the billing terms above.

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