Medical Care Health Document

MEDICAL CARE HEALTH AGREEMENT

Patient Name:    Date of Birth:

Provider Name:    Provider Contact:

WHEREAS

WHEREAS, Patient desires to obtain medical assessment, diagnosis and treatment services as described herein, and Provider is duly qualified and authorized to provide such services in accordance with applicable standards of care; and

WHEREAS, Provider agrees to provide medical care to Patient on the terms set forth in this Agreement and Patient consents to the provision of such care after being informed of the expected scope, potential risks, and alternatives; and

WHEREAS, the parties desire to set forth their respective obligations concerning scope of care, payment, confidentiality, and other terms governing the provision of services.

SCOPE OF WORK

Provider shall deliver medical services, diagnostics, treatments and/or procedures as indicated by Patient's condition and as agreed between the parties. Services to be provided (provide specific details below):

MEDICAL HISTORY & AUTHORIZATIONS

PAYMENT TERMS

Patient agrees to pay Provider the fees for services described below. Payment terms are as follows:

Late payment: Provider may impose a late fee of on balances not paid within days of the due date.

Credit Card   Check   Cash   Assignment to Insurance

TERM AND TERMINATION

This Agreement commences on and continues until unless earlier terminated in accordance with this Section.

Either party may terminate this Agreement for any reason upon providing the other party with days' written notice. Provider may suspend services immediately if Patient fails to pay amounts due, subject to any applicable emergency or continuity-of-care obligations.

CONFIDENTIALITY

Provider shall maintain the confidentiality of Patient's medical and personal information that is generated or obtained in the course of providing services (Protected Health Information). Provider will not disclose such information except as authorized by Patient in writing, as necessary for treatment, payment or healthcare operations, or as required by law, court order, or where there is a substantial risk of imminent harm to Patient or others. Provider will implement reasonable administrative, physical, and technical safeguards to protect confidential information.

Patient acknowledges and agrees that limited disclosures may be made to third-party consultants or specialists retained by Provider for consultation, provided such parties agree to maintain confidentiality consistent with this Agreement.

Patient acknowledges receipt of and understands Provider's confidentiality practices.

GOVERNING LAW

This Agreement shall be governed by and construed in accordance with the laws of the state of without regard to its conflict of law principles.

ENTIRE AGREEMENT

This Agreement, including any written attachments or exhibits executed by the parties, constitutes the entire agreement between Patient and Provider with respect to the subject matter hereof and supersedes all prior agreements, representations and understandings, whether oral or written. Any amendment must be made in writing and signed by both parties.

NOTICES

ADDITIONAL ACKNOWLEDGMENTS

Patient represents that the information provided in this Agreement is accurate to the best of Patient's knowledge, that Patient has had the opportunity to ask questions regarding the proposed care and alternatives, and that Patient consents to the care described herein.

Patient hereby gives informed consent to the treatment, procedures and services described in this Agreement and authorizes Provider and Provider's authorized personnel to perform such services.

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