This Agreement is entered into as of [Date] by and between:

[Facility Name]
Address: _________________________________
Contact: _________________________________
("Facility")

and

[Visiting Nurse Agency Name]
Address: _________________________________
Contact: _________________________________
("Nurse Agency")

with respect to the provision of limited, patient-specific infusion services for:

Patient Name: __________________________________
Date of Birth: ____________________________________
Diagnosis: Bleeding disorder requiring infusion/injection treatment
Treating Hematologist: _____________________________
Hemophilia Treatment Center (HTC): __________________

1. Purpose

The purpose of this agreement is to permit the Nurse Agency to provide infusion (or injection) services for the above-named patient at the Facility on a limited, one-time or time-limited basis, during the patient's admission to the Facility for substance use disorder treatment.

2. Scope of Services

The Nurse Agency agrees to:

• Administer prescribed bleeding disorder medication per the hematologist’s orders and treatment protocol;
  

• Document each administration appropriately;
  

• Bring and use their own sterile infusion supplies and disposal equipment (including sharps containers);
  

• Coordinate scheduling with the Facility to minimize disruption to treatment activities;
  

• Immediately report any adverse reaction or medical concern to the Facility staff and the treating hematologist.
  

3. Facility Responsibilities

The Facility agrees to:

• Permit the Nurse Agency to access the patient at agreed-upon times and in a private, clean, and safe space appropriate for medical procedures;
  

• Facilitate communication between the Nurse Agency, Facility clinical staff, and the patient;
  

• Notify the Nurse Agency of any schedule or condition changes affecting the patient’s availability;
  

• Comply with applicable infection control and patient privacy standards.
  

4. Licensing and Compliance

The Nurse Agency affirms that all staff providing services under this agreement are:

• Licensed and in good standing to practice in the state of [Insert State];
  

• Covered by professional liability insurance;
  

• Trained in infusion procedures and familiar with bleeding disorder treatment protocols;
  

• Compliant with HIPAA and other applicable privacy and confidentiality laws.
  

5. Duration and Termination

This agreement shall be effective as of [Start Date] and shall remain in effect until [End Date or “until the patient is discharged”], unless terminated earlier by either party with 24 hours’ written notice.

6. Indemnification

Each party agrees to indemnify, defend, and hold harmless the other party from any and all claims, damages, or liabilities arising out of its own acts or omissions under this Agreement, except to the extent caused by the negligence or willful misconduct of the other party.

7. Miscellaneous

• This agreement is intended solely for the care of the named patient and does not establish a general provider relationship between the parties.
  

• Nothing in this agreement shall be construed to create a partnership or employment relationship.
  

• This agreement is governed by the laws of the state of [Insert State].

IN WITNESS WHEREOF, the parties have executed this Single Use Case Agreement as of the date first written above.

[Facility Name]
By: _____________________________________
Title: ___________________________________
Date: ___________________________________

[Visiting Nurse Agency Name]
By: _____________________________________
Title: ___________________________________
Date: ___________________________________