Healthcare Wellness Plan Agreement

HEALTHCARE WELLNESS PLAN AGREEMENT

Parties and Effective Date

Provider Name:    Provider Address:

Patient Name:    Date of Birth:

Gender:    Patient Address:

Primary Phone:    Emergency Contact:

Effective Date of Plan:

Plan Description and Services

The Provider agrees to deliver a tailored wellness plan to the Patient. The plan may include, as applicable, health screening, nutrition counseling, exercise prescription, stress management, behavioral coaching, biometric monitoring, health education, and coordination with other healthcare professionals. Patient acknowledges that the specific services to be delivered are set forth below and may be modified by mutual written agreement.

Frequency:    Duration:    Location:

Fees, Billing, and Insurance

Patient agrees to pay fees for services as listed below. Provider will bill Patient or, if authorized, the insurer identified by Patient. Patient is responsible for deductibles, copayments, and any charges not covered by insurance.

Total Plan Fee:    Payment Schedule:

Authorization to bill insurer and accept assignment of benefits:   I authorize billing to my insurer and assignment of benefits to Provider where applicable.

Medical History and Risk Information

Consent, Risks, and Patient Responsibilities

Patient acknowledges that participation in wellness activities and clinical recommendations may involve risks, including but not limited to muscle soreness, injury, allergic reaction, or exacerbation of underlying conditions. Provider has explained the nature and purpose of the wellness plan, reasonable foreseeable risks, potential benefits, and available alternatives. Patient affirms that questions have been answered and that participation is voluntary.

Patient Responsibilities: follow prescribed recommendations, disclose changes in health status, attend scheduled sessions or provide timely notice of cancellation, and comply with agreed payment arrangements.

Right to Withdraw: Patient may withdraw consent and discontinue participation at any time by providing written notice to Provider. Withdrawal does not relieve Patient of financial obligations for services already rendered or for cancellation fees as described below.

Privacy, Data Sharing, and Authorization

Patient acknowledges receipt of the Provider's privacy practices and agrees that Provider may use and disclose protected health information as necessary to provide services, obtain payment, and for healthcare operations. Patient authorizes Provider to communicate health information to third parties as designated below and to exchange information with other treating providers for care coordination.

Authorization Expiration Date:

Patient consents to the use of telehealth modalities where clinically appropriate:   Yes

Liability, Indemnification, and Governing Law

Except for willful misconduct or gross negligence, Provider's liability for any claim arising from this Agreement is limited to direct damages up to the total fees paid by Patient under this Agreement. Patient agrees to indemnify and hold Provider harmless from claims arising from Patient's failure to follow recommendations or from misrepresentations in Patient's medical history.

This Agreement shall be governed by the laws of the state in which Provider practices. Any dispute that cannot be resolved by negotiation shall be submitted to mediation prior to filing litigation; if mediation fails, the parties may pursue remedies in a court of competent jurisdiction.

Amendment, Termination, and Entire Agreement

This Agreement constitutes the entire understanding between the parties with respect to the wellness plan. Any modification or amendment must be in writing and signed by both parties. Provider may terminate services for failure to comply with plan terms or for nonpayment, subject to any applicable notice requirements.

Acknowledgment and Certification

By signing below, Patient certifies that the information provided in this Agreement is accurate and complete to the best of Patient's knowledge, that Patient has read and understands the terms of the wellness plan, including risks and financial obligations, and that Patient consents to the provision of the services described herein.

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