Healthcare Wellness Quote

HEALTHCARE WELLNESS QUOTE

Quote Number:   |  Quote Date:   |  Prepared By:

Patient / Client Information

Date of Birth:   Gender:

Insurance Information (if applicable)

Medical History — Summary

Itemized Wellness Services & Fees

Enter the services covered by this quote. Amounts should be provided as U.S. dollars.

Terms, Conditions, and Privacy

Scope of Services: The services set forth in this quote are limited to the descriptions above. Additional services requested by the patient or client will be provided only upon written amendment to this quote and may result in additional fees.

Payment Terms: Unless otherwise specified in writing, payment in full is due within 30 days of invoice. Client is responsible for co-payments, deductibles, and charges not reimbursed by insurance. If Client elects to have the Provider submit claims to an insurer, Client authorizes release of necessary information for claims processing but remains ultimately responsible for payment.

Cancellation and Rescheduling: Cancellations made less than 48 hours prior to scheduled services may incur a cancellation fee up to 50% of the scheduled service fee. Rescheduling requests are subject to Provider availability.

Confidentiality and Protected Health Information (PHI): Provider will maintain confidentiality of PHI in accordance with applicable privacy laws. By accepting this quote, Client provides limited authorization for the use and disclosure of PHI to the extent necessary to provide services and process claims as described herein. This authorization expires on: .

Limitation of Liability: To the maximum extent permitted by law, Provider's liability for any claim arising from or related to services performed under this quote is limited to direct damages not to exceed the total fees actually collected for the specific services giving rise to the claim. Provider is not liable for indirect, incidental, special, or consequential damages.

No Guarantee of Specific Outcomes: Client acknowledges that wellness services and interventions involve variable results. Provider makes no guarantees regarding specific health outcomes, weight loss, clinical markers, or other measures of results.

Expiration of Quote: This quote is valid until . Fees and availability are subject to change after that date.

Acknowledgments and Authorizations

  I acknowledge receipt of the Provider's privacy practices and authorize the use and disclosure of my protected health information as necessary to perform the services and process claims described in this quote.

  I authorize the Provider to submit claims to my insurance carrier as indicated above. I understand that authorization to bill insurance does not relieve me of my financial responsibility for unpaid balances.

Sign Now