Patient-Provider Treatment Agreement

Practice Information

Practice Name: _________________________________ Provider Name: _________________________________ Address: _______________________________________ Phone: ________________________________________

Patient Information

Name: _________________________________________ Date of Birth: __________________________________ Address: _______________________________________ Phone: ________________________________________

Agreement Terms

1. Mutual Responsibilities

Provider agrees to:

• Provide comprehensive medical care according to current standards
• Maintain patient confidentiality per HIPAA regulations
• Respond to urgent medical concerns within 24 business hours
• Provide clear explanations of diagnoses and treatment options
• Coordinate care with other healthcare providers when necessary

Patient agrees to:

• Provide accurate and complete health information
• Keep scheduled appointments or give 24-hour notice of cancellation
• Follow agreed-upon treatment plans
• Pay all required copays and fees at time of service
• Update contact and insurance information promptly

2. Appointment Policies

• Regular office visits: 24-hour cancellation notice required
• No-show fee: $____ for missed appointments without notice
• Late arrival may result in rescheduling

3. Prescription Policies

• Medication refills require 72-hour notice
• Controlled substances require in-person visits
• Lost prescription replacement fee: $____

4. Communication

• Emergency situations: Call 911 or go to nearest ER
• Non-urgent matters: Use patient portal or office phone
• After-hours contact procedures: _________________

5. Financial Responsibility

• Insurance claims filing responsibility
• Payment of deductibles, co-insurance, and non-covered services
• Payment plans available upon request

Signatures

Provider Signature: _________________ Date: _______

Patient Signature: __________________ Date: _______

Valid for one year from date of signing