Healthcare Wellness Agreement

HEALTHCARE WELLNESS AGREEMENT

This Healthcare Wellness Agreement ("Agreement") sets forth the terms and conditions under which the Provider identified below will deliver wellness, preventative, or therapeutic services to the Patient identified below. The parties agree as follows.

Parties and Effective Date

Patient Name:

Provider / Clinic Name:

Agreement Effective Date:

Patient Information

Insurance Information

Medical History / Current Health

Scope of Services

Provider will deliver wellness services as agreed and documented in the patient's individualized care plan, which may include assessment, nutritional counseling, lifestyle coaching, preventative screenings, and low-risk therapeutic modalities. Services do not include emergent medical care or surgical intervention unless explicitly agreed in writing. Specific services to be provided:

Risks, Benefits, and Alternatives

The Patient acknowledges that wellness services carry inherent risks and benefits. Provider has explained material risks, anticipated benefits, and reasonable alternatives to the proposed services. The Patient understands results cannot be guaranteed and agrees to notify Provider promptly of any adverse response to care.

Fees, Billing, and Payments

Patient agrees to pay fees for services in accordance with Provider's schedule. Insurance billing is a courtesy; the Patient remains ultimately responsible for all charges not covered by insurance, including co-payments, deductibles, and services denied by an insurer.

Cancellation and No-Show Policy

Patient agrees to provide at least 24 hours' notice to cancel or reschedule appointments. Provider may charge a cancellation or no-show fee as set forth in the payment terms above. Repeated missed appointments may result in termination of services.

Confidentiality and Privacy Acknowledgment

Provider maintains confidentiality of health information in accordance with applicable privacy laws. By signing, Patient acknowledges receipt of Provider's privacy practices and consents to the use and disclosure of protected health information for treatment, payment, and healthcare operations consistent with those practices.

Consent to Treatment and Release

Patient hereby consents to evaluation and treatment by Provider, including non-invasive wellness techniques and counseling as indicated in the planning section. Patient authorizes Provider to share necessary medical information with other treating clinicians or payors when required for continuity of care or payment.

Limitation of Liability and Indemnification

Except for gross negligence or willful misconduct, Provider's liability for any claim arising from services under this Agreement shall be limited to direct damages not to exceed the amount paid by Patient to Provider for the specific service giving rise to the claim. Patient agrees to indemnify and hold Provider harmless from claims arising from Patient's failure to disclose relevant medical history or from Patient's noncompliance with treatment recommendations.

Term, Termination, and Expiration of Authorization

This Agreement remains in effect until terminated by either party in writing. Patient may withdraw consent at any time by delivering written notice to Provider, subject to obligations to pay for services already rendered. Authorizations for release of information expire on the date below unless earlier revoked.

Acknowledgements and Certifications

By signing below, Patient certifies that the information provided is true and complete to the best of Patient's knowledge, that Patient has disclosed all material medical history relevant to proposed services, and that Patient has had an opportunity to ask questions and receive answers regarding services, risks, benefits, alternatives, and fees.

Additional Terms

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