Healthcare Wellcare Agreement

HEALTHCARE WELLCARE AGREEMENT

This Healthcare Wellcare Agreement (the Agreement) is entered into by and between Provider Name: and Patient Name: , with an Effective Date of .

Recitals

WHEREAS, the Provider delivers preventive, wellness and coordinated care services designed to maintain and improve patient health; and WHEREAS, the Patient seeks enrollment in the Provider’s Wellcare program and agrees to the terms and conditions set forth in this Agreement.

1. Scope of Services

Provider shall furnish Wellcare services including preventive screenings, wellness planning, chronic disease monitoring, patient education, care coordination with other health professionals, and routine follow-up as detailed in the Wellcare Plan below. Services rendered are subject to clinical appropriateness and professional judgment.

2. Term and Termination

The Agreement begins on the Effective Date and continues until terminated by either party upon thirty (30) days prior written notice. Provider may terminate immediately for reasons including material breach, nonpayment of agreed fees, or risk to patient safety. Patient may withdraw consent at any time consistent with Section 6.

3. Patient Information

4. Insurance Information

5. Medical History and Current Health

Please indicate chronic conditions that apply:

6. Consent and Authorization

By signing this Agreement, Patient authorizes Provider to provide Wellcare services described herein. Patient consents to Provider accessing medical records, coordinating care with identified healthcare professionals, and communicating with Patient and emergency contacts regarding care needs.

Patient retains the right to withdraw consent at any time by providing written notice to Provider. Withdrawal of consent will not affect actions taken by Provider prior to receipt of withdrawal.

7. Fees, Billing and Payment

Wellcare services may be covered by insurance; however, Patient is responsible for co-payments, deductibles, or fees not covered by insurance. Provider will bill insurance when applicable and bill Patient for outstanding balances.

8. Confidentiality and Privacy

Provider shall maintain the confidentiality of Patient information in accordance with applicable law and the Provider’s privacy practices. Patient acknowledges receipt of the Provider’s privacy notice and understands how protected health information will be used and disclosed for care coordination, treatment, payment and healthcare operations.

9. Liability and Indemnification

Provider will perform services with reasonable care commensurate with professional standards. Except as prohibited by law, Patient agrees to indemnify and hold Provider harmless from claims arising out of Patient’s failure to provide accurate information or follow recommended care. Provider’s liability for any claim related to services is limited to direct damages and shall not include consequential damages.

10. Notices

Notices required under this Agreement shall be in writing and delivered to the contact information provided by each party. Provider contact name and office:

11. Authorization Expiration

This authorization to provide Wellcare services and access medical information expires on unless earlier revoked in writing by Patient.

12. Miscellaneous

This Agreement constitutes the entire understanding between the parties regarding Wellcare services and supersedes prior agreements. Any amendment must be in writing signed by both parties. If any provision is held invalid, the remaining provisions shall remain in effect.

Patient acknowledges receipt of a copy of this Agreement and confirms that all information provided herein is true and complete to the best of Patient’s knowledge.

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