Healthcare Terms & Conditions

HEALTHCARE TERMS & CONDITIONS

Patient Name:   Date of Birth:

Patient Information

Insurance Information

Medical & Clinical History

Terms of Treatment, Billing, and Consent

Consent to Treatment: By signing below, the patient or authorized representative consents to such diagnostic and therapeutic services, including examinations, tests, procedures, and medications, as are deemed medically necessary by authorized clinical staff. The patient affirms that they have had an opportunity to ask questions regarding proposed care and that those questions have been answered to the patient’s satisfaction.

Financial Responsibility and Assignment of Benefits: The patient agrees to be responsible for all charges for services rendered if not paid in full by the patient’s insurer. The patient authorizes direct payment of insurance benefits to the treating provider and assigns to the provider any right to such benefits to the extent necessary to collect for services rendered. The patient understands co-payments, deductibles, co-insurance amounts, and non-covered services are due at the time of service or as otherwise agreed.

Collections and Legal Remedies: If the account is referred for collection or legal action, the patient agrees to pay reasonable collection costs, attorney fees, and court costs as permitted by law. The provider may release necessary medical and financial information to collection agents, attorneys, or courts as required to effect collection.

Authorization to Release Medical Information

The patient authorizes the release of medical information, including medical records and billing information, to the patient’s insurer(s), referring providers, other treating providers, and their authorized agents for purposes of treatment, payment, and health care operations. This authorization includes the release of information relating to behavioral health, communicable diseases, and substance use disorders where necessary for claims processing and treatment coordination.

Privacy Notice & HIPAA Acknowledgment

The patient acknowledges receipt of the provider’s Notice of Privacy Practices describing how protected health information may be used and disclosed, the patient’s rights concerning that information, and the provider’s legal duties. The patient understands that the Notice is available upon request and that the provider is required by law to maintain the privacy and security of protected health information except as permitted or required by law.

Electronic Communications: The patient consents to receiving appointment reminders, billing statements, and other communications by phone, text message, voicemail, or email at the contact information provided unless the patient opts out in writing.

Right to Withdraw & Revocation

The patient may revoke authorizations provided in this document at any time by submitting a signed written revocation to the provider’s medical records or compliance office, except to the extent that the provider has already acted in reliance upon the authorization. Revocation does not affect disclosures made prior to receipt of the revocation.

Miscellaneous

Governing Law and Dispute Resolution: This agreement shall be governed by applicable state law. Any dispute arising out of or related to treatment, billing, or this agreement will first be submitted to good faith negotiation. If unresolved, the parties may seek mediation or other alternative dispute resolution prior to litigation, except where injunctive relief is sought.

Limitations of Liability: Except as prohibited by law, the provider’s liability for any claim related to professional services shall be limited to proven direct damages and shall exclude punitive or consequential damages to the fullest extent permitted by law.

Certification: I certify that the information provided on this form is true and correct to the best of my knowledge. I understand and agree to the terms and conditions set forth above, and I authorize the release and use of my health information as described.

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