Healthcare Support Agreement

Healthcare Support Agreement

This Healthcare Support Agreement ("Agreement") is entered into by and between Provider Name: and Client Name: Effective Date:

Patient Information

Male Female Other Prefer not to say

Emergency Contact

Insurance Information

Medical History & Clinical Information

Scope of Services

Provider shall furnish the healthcare support services described below (Services) to Client within the Provider's scope of licensure, training, and applicable law. Services may include personal care assistance, medication reminders, mobility assistance, wound dressing changes when within scope, assistance with activities of daily living, and care coordination as specifically listed in the Service Plan section.

Service Start Date:    Anticipated End Date (if any):

Days of Week: Mon Tue Wed Thu Fri Sat Sun

Fees, Billing & Payment

Client agrees to pay Provider the fees set forth below. Billing shall commence on the Service Start Date. Provider may bill Client or Client's insurer as authorized; Client remains responsible for charges not paid by insurer.

Consent, Authorization & HIPAA Acknowledgment

By signing this Agreement, Client authorizes Provider to deliver the Services described herein and to access, use and disclose protected health information (PHI) as reasonably necessary to provide, coordinate and bill for those Services. Provider will protect PHI in accordance with applicable law. This authorization permits disclosure of PHI to other health care professionals, pharmacies, payers and emergency personnel when necessary for treatment, payment or operations.

Client acknowledges the right to revoke this authorization in writing, except to the extent Provider has already acted in reliance on it. Client understands that revocation does not affect disclosures already made under this authorization.

Client grants permission for Provider to communicate appointment, care, and billing information to the following persons (if any):

Emergency Care / Transport

In the event of an emergency, Provider may arrange or seek emergency medical services (including emergency transport) for Client. Client hereby consents to such emergency measures if, in the judgment of Provider or emergency personnel, they are necessary to preserve life or prevent significant harm. Client is responsible for related expenses not covered by insurance.

Indicate consent to emergency transport: I consent I decline

Client & Provider Responsibilities

Client agrees to provide accurate medical history, maintain required supplies and medications, grant Provider reasonable access to the premises, and notify Provider of changes in health status. Provider will provide services in a professional manner, ensure staff have required training, and report incidents and suspected abuse as required by law.

Termination & Modification

Either party may terminate this Agreement for any reason with seven (7) days' written notice, unless otherwise required by law or contract with a payer. Provider may suspend services immediately if Client's condition presents a safety risk to staff or others. Modifications to this Agreement must be in writing and signed by Client and an authorized representative of Provider.

Liability, Indemnification & Remedies

Provider shall exercise reasonable care in providing Services. To the fullest extent permitted by law, Client releases Provider from liability for ordinary negligence and agrees to indemnify and hold Provider harmless from claims arising from Client's failure to disclose material health information, failure to follow Provider instructions, or willful misconduct by Client or third parties. This section does not limit rights that cannot be waived under applicable law.

Reporting & Quality Assurance

Provider will document services rendered and report adverse events, incidents, and suspected abuse to appropriate authorities as required. Client consents to routine quality assurance activities and clinical record reviews conducted by Provider.

Miscellaneous

Governing Law: This Agreement is governed by the laws of the state in which Services are delivered. If any provision is held invalid, remaining provisions remain in effect. This Agreement constitutes the entire agreement between the parties concerning the Services and supersedes prior oral or written agreements.

Acknowledgments

Client acknowledges receipt of this Agreement, understands the nature of the Services, the potential risks and benefits, and the right to withdraw consent except as limited by law. Client affirms that information provided is true and complete to the best of Client's knowledge.

Capacity to Consent: Client can personally consent Guardian/Representative consents on behalf of Client

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