Healthcare Tier Agreement

HEALTHCARE TIER AGREEMENT

This Healthcare Tier Agreement ("Agreement") is made and entered into as of Effective Date: by and between Provider Name: and Patient/Member Name: .

RECITALS

WHEREAS, Provider is a licensed healthcare provider offering a range of clinical and ancillary services; and WHEREAS, Patient/Member desires to elect a defined tier of services and enter this Agreement setting forth the scope, fees, billing practices, privacy authorizations, and termination provisions applicable to the selected tier.

PATIENT INFORMATION

INSURANCE INFORMATION

MEDICAL HISTORY

TIER SELECTION

Select one or more tiers that will govern the scope of covered services, member access, and fees:

Basic Tier — Core preventive and urgent care services with limited specialist access.

Standard Tier — Basic services plus expanded specialist referrals and limited telehealth visits.

Premium Tier — Comprehensive access including care coordination, enhanced telehealth, and priority scheduling.

Custom Tier — Specific services defined below.

SCOPE OF SERVICES

Provider shall deliver services consistent with the selected tier(s). Provider retains discretion to determine clinical appropriateness of services within professional standards. Services not expressly included in the selected tier will be billed separately at Provider's standard rates unless prior written authorization is obtained.

FEES, BILLING AND PAYMENT

Patient/Member shall pay the fees associated with the selected tier. Provider will invoice Patient/Member or bill Patient/Member's insurance according to the selections below and applicable law.

Authorization to bill insurance: Patient/Member hereby authorizes Provider to submit claims to the listed insurance for covered services and to accept payments from the insurer on Patient/Member's behalf.

PRIVACY, HIPAA AUTHORIZATION AND RELEASE

Provider's use and disclosure of protected health information ("PHI") shall be governed by applicable privacy laws. Patient/Member acknowledges receipt of Provider's Notice of Privacy Practices where provided. Patient/Member specifically authorizes Provider to disclose PHI to third-party payers, care coordinators, and other delegates as necessary for treatment, payment, and healthcare operations, subject to the limits stated herein.

Acknowledgment of Notice of Privacy Practices: I acknowledge receipt of the Notice of Privacy Practices.

TERMS OF TERMINATION

Either party may terminate this Agreement upon written notice to the other party. Unless otherwise specified, termination shall be effective upon the later of receipt of notice or the expiration of the notice period set forth below. Termination does not relieve Patient/Member of obligations to pay amounts outstanding for services rendered prior to termination.

LIMITATION OF LIABILITY; INDEMNIFICATION

To the fullest extent permitted by law, Provider's liability for claims arising under this Agreement shall be limited to direct damages up to the aggregate of fees paid by Patient/Member under this Agreement in the preceding twelve (12) months. Neither party shall be liable for indirect, incidental, special, punitive, or consequential damages. Patient/Member agrees to indemnify and hold Provider harmless from claims arising out of Patient/Member's breach of this Agreement or misuse of services.

DISPUTE RESOLUTION; GOVERNING LAW

Parties shall attempt to resolve disputes in good faith. If unresolved, disputes shall be resolved by binding arbitration under the applicable rules selected by Provider, unless otherwise prohibited by law. This Agreement shall be governed by the laws of the state specified below, without regard to conflicts of law principles.

NOTICES

GENERAL PROVISIONS

This Agreement constitutes the complete agreement between the parties concerning tiered services and supersedes prior oral or written agreements. Any amendment must be in writing and executed by both parties. If any provision is held invalid, the remaining provisions shall remain in full force and effect.

Right to withdraw: Patient/Member may revoke authorizations herein to the extent permitted by law; revocation will not affect disclosures or actions taken in reliance on the authorization prior to revocation, nor will it relieve Patient/Member of obligations to pay for services already rendered.

AUTHORIZATION AND CERTIFICATION

By signing below, Patient/Member certifies that the information provided in this Agreement is true and correct, that Patient/Member consents to the delivery of healthcare services consistent with the selected tier(s), and that Patient/Member has read and understands the terms, billing practices, privacy authorizations, and termination provisions set forth herein.

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