Healthcare Terms and Conditions

HEALTHCARE TERMS AND CONDITIONS

This Healthcare Terms and Conditions Agreement (Agreement) governs the relationship between the parties identified below and describes the rights and obligations relating to provision of clinical services, billing, privacy of health information and consent to treatment. Patient Name: Provider Name: Effective Date:

Patient Information

Insurance Information

Medical History

Financial Terms and Billing

Patient is responsible for all charges for services rendered. Provider will bill insurance as a courtesy where permitted; however patient remains ultimately responsible for any amounts not covered by insurance, including co-payments, deductibles and non-covered services. Responsible party for payment:

If patient elects to provide a payment card for automatic billing of balances, patient authorizes Provider to charge the card on file for outstanding balances after attempted billing of insurance. Patient agrees to pay late fees and reasonable collection costs on delinquent accounts as permitted by law.

Consent to Treatment

Patient hereby voluntarily consents to examinations, diagnostic tests, medical and/or surgical treatments and procedures which may be recommended by Provider. Patient acknowledges that no guarantee has been made as to the results of any treatment. Patient retains the right to refuse any recommended treatment, except to the extent otherwise required by law. By signing this Agreement patient also consents to routine sharing of health information with other treating clinicians for coordination of care.

Privacy, Uses and Disclosures of Health Information

Provider will maintain the privacy of patient’s protected health information in accordance with applicable law. Patient authorizes Provider to use and disclose health information as necessary for treatment, payment, and healthcare operations, including disclosure to insurers, consulting providers and billing agents. Patient also authorizes release of medical information to designated persons and entities for continuity of care and payment.

Acknowledgment of receipt of Provider's Notice of Privacy Practices:

Telehealth and Remote Services

Patient consents to telehealth encounters when offered or requested. Telehealth services may include video, audio, or asynchronous communications. Patient understands limitations of remote evaluation and the possibility of technical failure. Patient agrees that Provider may document telehealth encounters in the medical record and share information with other treating providers as appropriate.

Cancellation, No-Show and Termination

Patient agrees to provide at least 24 hours' notice to cancel or reschedule appointments unless an emergency exists. Provider may assess a late cancellation or no-show fee in accordance with Provider's published policy. Provider reserves the right to terminate the clinician-patient relationship for noncompliance with these Terms, failure to pay for services, or disruptive behavior.

Liability, Indemnification and Dispute Resolution

Provider will exercise reasonable skill and care in delivering services. To the extent permitted by law, Provider's liability for any claim arising out of services provided is limited to direct damages and shall exclude incidental or consequential damages. Patient agrees to indemnify and hold Provider harmless from claims arising from patient's failure to provide accurate information or follow instructions. Any dispute arising out of this Agreement shall be resolved by the procedures set forth in Provider's standard dispute resolution policy, subject to applicable law.

Miscellaneous Provisions

Governing Law: This Agreement shall be governed by the laws of the jurisdiction in which Provider's principal office is located, to the extent not preempted by controlling federal law.

Severability: If any provision of this Agreement is held invalid or unenforceable, the remainder of the Agreement shall remain in full force and effect.

Entire Agreement and Amendments: This Agreement, together with any accompanying forms and notices, constitutes the entire agreement between Patient and Provider regarding the subjects herein. Provider may amend these Terms by providing notice to Patient in a manner consistent with Provider's policies.

Acknowledgment and Authorization

By signing below, Patient affirms that the information provided on this form is true and correct to the best of Patient's knowledge, that Patient has read and understands these Terms and Conditions, and that Patient authorizes Provider to render care and to use and disclose health information as set forth above.

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