THIS AGREEMENT is made on the …………..day of………….20……., (hereinafter, “Effective Date”) entered into by the Patient and the Health Care Provider (Patient and Health Care Provider collectively referred to as the “Parties” or individually as the “Party”) and includes that Party’s successors and assigns.
In consideration of covenants and agreements contained in this agreement, and other good and valuable consideration, the receipt of which is hereby acknowledged, Parties agree to the following terms and conditions and to be bound thereby:
This agreement shall be valid from the Effective Date until _____________________.
The Health Care Provider shall provide health care services and products (hereinafter “Services”) to the Patient per accepted industry standards and the provisions of this Agreement.
Once the Services are selected, the Patient will receive an invoice which amount shall be due and payable upon receipt by the Patient. INDIVIDUALS WHO ARE NOT ENROLLED IN A PLAN OR COVERAGE OR A FEDERAL HEALTH CARE PROGRAM (UNINSURED INDIVIDUALS), OR INDIVIDUALS WHO ARE ENROLLED BUT NOT SEEKING TO FILE A CLAIM WITH THEIR PLAN OR COVERAGE (SELF-PAY INDIVIDUALS) SHALL BE SUBJECT TO THE GOOD FAITH ESTIMATE PROVIDED IN APPENDIX 1.
A Party shall indemnify the other Party from and against all claim, loss, and damage caused by them in connection with this Contract. In the event the claim, loss, or damage are caused jointly by the Parties, the claims, loss, or damage shall be borne by each Party in proportion to their degree of contribution to the claim, loss, or damage.
The relationship of the parties hereto is that of an independent contractor. Accordingly, the Parties hereto are not deemed agents, partners, or joint venturers of the others for any purpose due to this agreement or the transactions contemplated thereby.
The Patient shall not transfer or assign this agreement without the Health Care Provider’s consent. However, the Health Care Provider may transfer or assign this agreement or subcontract its obligations hereunder at any time without the Patient’s consent. If the Health Care Provider does so, anyone to whom the Health Care Provider transfers, assigns, or subcontracts any or all of its obligations will have all of the Health Care Provider’s rights with respect to such obligations.
All non-public, confidential, or proprietary information of a Party (Disclosing Party), whether disclosed orally or disclosed or accessed in written, electronic or other form or media, and whether or not marked, designated or otherwise identified as “confidential” in connection with this Contract is confidential, solely for the use of performing this Contract and may not be disclosed or copied unless authorized in advance by the Disclosing Party in writing. Upon the Disclosing Party’s request, the other Party (Recipient Party) shall promptly return all documents and other confidential materials received from Disclosing Party.
Disclosing Party shall be entitled to injunctive relief for any violation of this Section. This Section does not apply to information that is: (a) in the public domain; (b) known to Recipient Party at the time of disclosure, or (c) rightfully obtained by Recipient Party on a non-confidential basis from a third party. In addition, this Agreement is confidential and cannot be divulged to third parties by a Party, unless as provided by law, without the written consent of the other Party.
For this agreement, “Force Majeure” means an event which a diligent party could not have reasonably avoided in the circumstances, which is beyond the control of a party and includes, but is not limited to, war, riots, civil disorder, earthquake, storm, flood or adverse weather conditions, strikes, lockouts or other industrial action, terrorist acts, confiscation or any other action by government agencies.
A Party’s failure to fulfill its obligations due to Force Majeure, shall not be considered a breach of this agreement, provided that the Party has taken all reasonable precautions, due care, reasonable alternative measures, and minimal delay all to carry out the terms of this agreement.
Either Party may terminate this agreement upon giving the other Party no less than _______________notice in writing. If a Party wishes to terminate the contract with less than this stated period, the other Party reserves the right to charge costs that they have already paid in advance or incurred.
The termination of this agreement shall not discharge the liabilities accumulated by either Party.
Any Clauses intended by the Parties or this agreement to survive the termination of this agreement shall survive the termination of this agreement by whatever cause.
Parties agree to settle disputes under this agreement through (select one)
☐Negotiation ☐Mediation ☐Arbitration ☐Litigation
In any action under this agreement, the prevailing Party shall be entitled to recover reasonable attorneys’ fees from the other Party, which fees shall be in addition to any other relief that may be awarded.
The Patient hereto agrees to perform any further acts and to execute and deliver any further documents that may be reasonably necessary to carry out the provisions of this Agreement.
CHANGES TO THE AGREEMENT
Either Party may request changes to the agreement, but they will only be effective if agreed in writing, signed by all Parties, and recorded. If any ambiguity is found in the agreement or various documents forming this agreement, the Parties shall issue any necessary clarification or instruction.
Except where otherwise provided, failure by the Health Care Provider to enforce any of these terms or conditions shall not be a waiver of their right to enforce them. No waiver by the Health Care Provider of any breach of, or of compliance with, any condition or provision of this Agreement by the Patient shall be considered a waiver of any other condition or provision or of the same condition or provision at another time.
The provisions of this agreement are severable. If any provision is held to be invalid or unenforceable, it shall not affect the validity or enforceability of any other provision.
This agreement may be executed in any number of counterparts, each of which shall be deemed to be an original and all of which taken together shall constitute one instrument.
This agreement constitutes the entire agreement between the Parties. It supersedes all prior oral or written agreements or understandings between the Parties concerning the subject matter of this agreement. All documents annexed to this agreement shall be subject to the terms under this agreement, provided that the Parties append their signatures on the documents. The Parties will exercise utmost good faith in this agreement.
The article and section headings in this agreement are for convenience; they form in no part of this agreement and shall not affect its interpretation.
All pronouns and any variations thereof shall be deemed to refer to the masculine, feminine, neuter, singular, or plural, as the identity of the person or entity may require. As used in this agreement: words of the masculine gender shall mean and include corresponding neuter words or words of the feminine gender, and words in the singular shall mean and include the plural and vice versa.
Any notice required to be given between the Parties pursuant to the provisions of this Agreement shall be in writing and shall be deemed to have been given at the time when actually received as a consequence of any effective method of delivery at the following addresses (including email) or such changed address as the Party shall have specified by written notice, provided that any notice of change of address shall be effective only upon actual receipt.
Health Care Provider: ________________________________________________________________
The Patient acknowledges that they have been provided with the opportunity to negotiate this agreement and to seek legal counsel before signing this agreement. In addition, the Patient acknowledges that they have entered into this agreement with the capacity and authority to contract freely and voluntarily.
This Agreement shall be governed in all respects by the laws of _______________________without regard to its conflict of law provisions.
IN WITNESS WHEREOF, each of the Parties has executed this agreement, as of the day and year set forth below.
If scheduled, list the date(s) the Primary Service or Item will be provided: [ ] Check this box if this service or item is not yet scheduled
Date of Good Faith Estimate: ____________/________/__________
Provider Name Estimated Total Cost
Provider Name Estimated Total Cost
Provider Name Estimated Total Cost
Total Estimated Cost: $
The following is a detailed list of expected charges for _______________________[LIST PRIMARY SERVICE OR ITEM], scheduled for _______________________________[LIST DATE OF SERVICE, IF SCHEDULED]. [Include if items or services are reoccurring, “The estimated costs are valid for 12 months from the date of the Good Faith Estimate.”]
[Provider/Facility 3] Estimate [Delete if not needed]
Provider/Facility Name Provider/Facility Type
City State ZIP Code
Contact Person Phone Email
National Provider Identifier Taxpayer Identification Number
Details of Services and Items for [Provider/Facility 3]
Address where service/item will be provided
[Street, City, State, ZIP]
[Service Code Type: Service Code Number]
Total Expected Charges from [Provider/Facility 3] $
Additional Health Care Provider/Facility Notes
Total estimated cost for all services and items: $
This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created.
The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.
If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.
You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.
You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill.
There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.
Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount
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