Health Form Fill

HEALTH DATA COLLECTION AND SERVICES AGREEMENT

This Health Data Collection and Services Agreement (the "Agreement") is entered into as of [Effective Date] (the "Effective Date") by and between [Company Name], a [Jurisdiction] corporation having its principal place of business at [Company Address] (“Provider”), and [Client Name], a [Jurisdiction] corporation having its principal place of business at [Client Address] (“Client”). Provider and Client may be referred to individually as a “Party” and collectively as the “Parties.”

RECITALS

WHEREAS, Provider is engaged in the business of health data management and administrative services; WHEREAS, Client desires to utilize the "Health Form Fill" portal and associated services for the secure intake of Protected Health Information (PHI) and administrative processing; WHEREAS, the Parties wish to define the scope of services, data security obligations, and liability limitations governing this engagement.

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1. OPERATIONAL DEFINITIONS

1.1 “Agreement” means this legal instrument, including all appendices, exhibits, and amendments hereto. 1.2 “Data Subject” means the natural person whose health information is being captured via the form. 1.3 “Health Form Fill” means the proprietary digital intake interface provided by Provider to facilitate the collection, storage, and transmission of medical and demographic data. 1.4 “PHI” means Protected Health Information as defined under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its implementing regulations. 1.5 “Services” means the provision of the digital intake platform, hosting, data encryption, and periodic maintenance as specified in Exhibit A. 1.6 “Fees” means the total consideration payable by Client to Provider in the amount of [Dollar Amount] per [Billing Cycle].

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2. SUBSTANTIVE TERMS AND OBLIGATIONS

2.1 Provision of Services: Provider shall grant Client a non-exclusive, non-transferable, revocable license to access the Health Form Fill platform for the duration of this Agreement. 2.2 Compliance: Provider represents and warrants that the Health Form Fill platform is developed in compliance with applicable federal and state data privacy laws, including but not limited to HIPAA. 2.3 Client Duties: Client shall ensure that all Data Subjects provide informed consent prior to the entry of any PHI into the Health Form Fill interface. 2.4 Data Security: Provider shall implement and maintain commercially reasonable administrative, physical, and technical safeguards to ensure the confidentiality, integrity, and availability of all PHI processed through the system. 2.5 Performance Metrics: Provider agrees to maintain an Uptime Availability SLA of 99.9%, excluding scheduled maintenance performed between [Time] and [Time].

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3. DEFAULT, TERMINATION, AND REMEDIES

3.1 Breach: A Party shall be in default if it fails to perform any material obligation under this Agreement. 3.2 Cure Period: The non-breaching Party shall provide written notice of default. The breaching Party shall have thirty (30) business days from receipt of such notice to cure the identified breach. 3.3 Termination for Cause: If a breach remains uncured after the 30-business-day period, the non-breaching Party may terminate this Agreement immediately upon written notice. 3.4 Remedies: In the event of an uncured breach, the non-breaching Party may seek damages, injunctive relief, or any other remedy available at law or in equity, subject to the limitations set forth in Section 4.

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4. BOILERPLATE LEGAL PROVISIONS

4.1 Severability: If any provision of this Agreement is held to be invalid or unenforceable, the remaining provisions shall continue in full force and effect. 4.2 Entire Agreement: This Agreement constitutes the final, complete, and exclusive statement of the terms of the agreement between the Parties and supersedes all prior understandings. 4.3 Force Majeure: Neither Party shall be liable for failure to perform due to causes beyond its reasonable control, including acts of God, war, terrorism, or systemic telecommunications failure. 4.4 Governing Law: This Agreement shall be governed by and construed in accordance with the laws of [Jurisdiction], without regard to its conflict of law principles. 4.5 Dispute Resolution: Any controversy arising out of this Agreement shall be settled by binding arbitration administered by the [Arbitration Association] in [City/State] in accordance with its Commercial Arbitration Rules.

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5. FORMAL EXECUTION BLOCK

IN WITNESS WHEREOF, the Parties, by their duly authorized representatives, have executed this Agreement as of the Effective Date.

FOR PROVIDER:

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Signature

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Name (Printed)

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Date

FOR CLIENT:

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Signature

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Name (Printed)

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Title

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Date