Patient Intake Agreement Form

In consideration of the instructions and care that Bay Area Endocrinology Associates, LLC (BAEA) provides to you, you acknowledge and agree to the following terms and conditions contained in these Patient Intake Agreements. Please sign as indicated below:

1. Consent for Purposes of Treatment, Payment, and Healthcare Operations: I consent to the use and disclosure of my protected health information for the purposes of treatment, payment, and healthcare operations.
Signature:

2. Waiver and Hold Harmless: I agree to waive and hold harmless BAEA from any claims arising out of the provision of services to me.
Signature:

3. Cooperation Agreement: I agree to cooperate fully with BAEA in the provision of medical services and to comply with the treatment plan prescribed.
Signature:

4. Medical Record Release: I authorize the release of my medical records to BAEA for the purpose of treatment and healthcare operations.
Signature:

5. Agreement to Pay for Services Rendered: I agree to pay for all services rendered by BAEA at the time of service.
Signature:

6. Financial Responsibility: I accept full financial responsibility for all charges incurred for my care and treatment.
Signature:

7. Disclosure: I acknowledge that I have been provided with BAEA's Notice of Privacy Practices and have been informed about the use and disclosure of my protected health information.
Signature:

8. Governing Law: I agree that this agreement shall be governed by and construed in accordance with the laws of the state in which BAEA operates.
Signature:

9. Entire Agreement: I acknowledge that this agreement constitutes the entire agreement between me and BAEA and supersedes all prior agreements and understandings, whether written or oral.
Signature:

10. Severability: If any provision of this agreement is held to be invalid or unenforceable, the remaining provisions shall remain in full force and effect.
Signature:

11. Indemnification: I agree to indemnify and hold harmless BAEA and its agents and employees from any and all claims, liabilities, damages, and expenses arising from my breach of this agreement.
Signature:

Patient Information:
Name:
Date of Birth:
Contact Number:
Email: