Neuro Spine Surgery Agreement

NEURO SPINE SURGERY AGREEMENT

This Neuro Spine Surgery Agreement (the "Agreement") is entered into as of Date: by and between Provider Name: (hereinafter "Provider"), and Patient Name: (hereinafter "Patient"). Provider and Patient are sometimes referred to collectively as the "Parties."

RECITALS

WHEREAS, Provider is a duly licensed neurosurgeon or physician with the training and experience to perform neuro spine surgical procedures, and maintains clinical privileges at the Facility identified below; and

WHEREAS, Patient has been evaluated by Provider and desires to undergo the surgical procedure described in Section 2 below subject to the terms, conditions, and acknowledgements set forth in this Agreement; and

WHEREAS, Provider and Patient intend by this Agreement to allocate risks, responsibilities for care and payment, and to document informed consent for the proposed procedure.

NOW THEREFORE, in consideration of the mutual promises herein, the Parties agree as follows:

1. DEFINITIONS

For purposes of this Agreement, the following terms shall have the meanings set forth below:

"Facility" means the hospital, ambulatory surgical center, or clinic at which the procedure will be performed. Facility Name:

"Procedure" means the neuro spine surgery described in Section 2 below, including any reasonably related diagnostic, therapeutic or ancillary procedures performed contemporaneously.

2. SCOPE OF SERVICES

Provider shall perform the following procedure (the "Procedure") on Patient at the Facility on or about the date indicated below, subject to medical necessity and intraoperative findings:

Anticipated Surgery Date:

3. PATIENT REPRESENTATIONS AND WARRANTIES

Patient represents and warrants that Patient has provided a complete medical history to Provider and has disclosed all known allergies, prior surgeries, medications (including anticoagulants and supplements), and current health conditions that may affect the Procedure.

4. RISKS, ALTERNATIVES, AND ACKNOWLEDGEMENTS

Provider has explained to Patient the nature and purpose of the Procedure, the reasonably foreseeable risks and complications (which may include, without limitation, infection, bleeding, neurologic deficit, paralysis, cerebrospinal fluid leak, instrument failure, need for additional surgery, anesthesia complications, and death), and the reasonable medical alternatives including non-surgical management. Patient acknowledges receipt of that explanation.

5. CONSENT TO PROCEDURE AND AUTHORIZATIONS

By signing this Agreement Patient gives informed consent for Provider and such assistants, consultants, residents, interns, nurses and other clinical personnel as Provider may designate to perform the Procedure and any ancillary procedures necessary to treat conditions discovered intraoperatively. Patient authorizes the administration of anesthesia and such blood transfusions or other treatments as, in Provider's reasonable judgment, are necessary in the event of complication.

Patient expressly acknowledges that the exact nature and extent of the Procedure may depend upon findings during surgery, and that Provider may perform additional procedures as are reasonably necessary in the exercise of professional judgment.

Patient has had the opportunity to ask questions and they have been answered to Patient's satisfaction.

6. FEES, PAYMENT, AND BILLING

Patient agrees to pay Provider for services rendered. Estimated professional fees and facility charges have been provided to Patient, but actual charges may differ based on intraoperative findings and postoperative care.

Patient authorizes Provider to bill Patient's insurance and to discuss billing and treatment with Patient's carrier. Patient remains responsible for deductibles, co-payments, co-insurance, and charges not covered by insurance.

7. INSURANCE ASSIGNMENT

Patient hereby assigns to Provider any right to payment from Patient's insurer for services rendered related to the Procedure, to the extent permitted by law, and authorizes Provider to pursue payment directly from those insurers on Patient's behalf.

8. CONFIDENTIALITY AND MEDICAL RECORDS

Provider will maintain Patient's medical records in accordance with applicable law. Patient authorizes Provider to release medical information to insurers, other treating providers, and as otherwise required by law or as necessary for continuity of care.

9. INDEMNIFICATION AND RELEASE

To the fullest extent permitted by law, Patient releases and agrees to indemnify and hold harmless Provider and Facility from liability for claims, costs, and damages arising out of Patient's failure to follow preoperative or postoperative instructions, misrepresentations in medical history, or consent to procedures described herein. This indemnity does not apply to conduct that is willful, grossly negligent, or criminal.

10. CANCELLATION, RESCHEDULING, AND NO-SHOW

Provider may cancel or postpone the Procedure for medical reasons or facility constraints. Patient must comply with preoperative instructions and timely arrival; repeated failure to appear or last-minute cancellations may result in fees and termination of scheduling privileges.

11. EMERGENCY TREATMENT

In the event of an emergency arising from or during the Procedure, Provider is authorized to take such actions as are medically necessary. Patient agrees that such emergency care will be billed in the ordinary course.

12. FOLLOW-UP CARE

Patient agrees to attend all scheduled postoperative appointments and to comply with wound care, medication instructions, activity restrictions, and rehabilitation recommendations. Failure to attend follow-up may adversely affect outcomes and records of care.

13. NOTICES

All notices required or permitted under this Agreement shall be in writing and delivered to the addresses set forth below by personal delivery, certified mail, or other delivery service that provides a receipt.

14. GOVERNING LAW

This Agreement shall be governed by and construed in accordance with the laws of the State whose courts shall have jurisdiction as specified by the Parties. Venue for any dispute shall be in the appropriate state or federal court within that jurisdiction.

15. ENTIRE AGREEMENT

This Agreement constitutes the entire agreement between the Parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, understandings and representations, whether oral or written, relating thereto.

16. SEVERABILITY

If any provision of this Agreement is held to be invalid or unenforceable, the remainder of this Agreement shall remain in full force and effect, and the invalid or unenforceable provision shall be reformed to the extent necessary to be valid and enforceable.

17. AMENDMENTS AND WAIVER

No modification, amendment or waiver of any provision of this Agreement shall be effective unless in writing and signed by both Parties. Failure to enforce any provision shall not constitute a waiver of that provision or any other provision.

18. COUNTERPARTS

This Agreement may be executed in counterparts, each of which shall be deemed an original but all of which together shall constitute one and the same instrument. Electronic or facsimile signatures shall be treated as original signatures for all purposes.

ACKNOWLEDGMENTS

By signing below Patient acknowledges that Patient has read and understands this Agreement, consents to the Procedure described herein, and has had the opportunity to ask questions and receive satisfactory answers. If Patient is signing through a legal guardian or authorized representative, such representative warrants their authority to consent on Patient's behalf.

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