Download SERVICE AGREEMENT AND ACKNOWLEDGMENT

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SERVICE AGREEMENT AND ACKNOWLEDGMENT
The undersigned, ____________________________________ wishes to enter into this Service Agreement
(the “Agreement”) with Home Care Associates, Inc., (d/b/a an independently owned and operated Home Instead
Senior Care franchise) (“Provider”) to provide ______________________________ (“Client”) with nonmedical homecare services including but not limited to assistance with personal care (toileting, bathing),
companionship, medication reminders, shopping, errands and light housekeeping.
Authorization for intake, assessments, homecare services and medical information:
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The undersigned authorize Provider to conduct a nursing assessment, a home safety assessment and
providing services, as requested by myself/representative and ordered by my physician. Services
provided by Provider include those indicated in the intake sheet that the undersigned provided to
Provider.
The services provided which Home Instead Senior Care will provide have been explained to me and the
undersigned understands that the undersigned and/or Client may refuse treatment within the confines of
the law after being informed of the consequences of such actions.
The undersigned gives consent and authorization for release of medical information to Home Instead
Senior Care by physicians and other health care providers, facilities.
The undersigned authorizes Home Instead to release copies of my medical records, reports or summaries
as may be relevant to other health care providers for the purpose of continuing and coordinating care and
for quality assurance
The undersigned authorizes Home Instead Senior Care and other licensing/ regulatory bodies to
periodically examine my medical record for the purpose of checking compliance to applicable rules,
regulations and standards.
I understand that it would be prudent and in my best interests to establish a plan in the event of an
emergency such as a fire, hurricane, severe snowstorm, or other natural disaster. Therefore, I hereby
grant Home Instead Senior Care permission to reveal to any government agency, supplemental provider
agency, community volunteer service or any other providers of services, medical records regarding my
care, except where otherwise prohibited by law.
Acknowledge Receipt:
I acknowledge receiving verbal and written information concerning: NYS Proxy Law/
Advance Directives, Homecare Bill of Rights, Privacy Policies
Rights and Responsibilities: I have fully reviewed the Bill of Rights and Responsibilities and accept all terms
Acknowledgement of Risks. I fully acknowledge that I have not hired Home Instead to provide personnel to be by
the Client’s side during every minute of the shifts I am requesting. As such, I understand that the duties of
Home Instead personnel entail many activities that require such personnel to leave the Client’s side (eg. including
but not limited to preparing a bedside bath, preparing clothing) and often times to leave the Client’s immediate
vicinity (eg. to cook or clean within the home) and/or leave the Client’s home (eg. to shop outside the home) or to
be sleeping at night (in the case of a Live-In assignment). Similarly, if Client refuses care or disallows any Home
Instead Senior Care employee from doing their job, included but not limited to, assisting with ambulation or
assisting in ways that are necessary to prevent injury, the Home Instead Senior Care employee cannot use
physical force to assist and must respect the Client’s right to refuse care under the NYS Patient Bill of Rights.
Accordingly, the Home Instead Senior Care employee and Home Instead are not responsible for any resulting
harm, injury or death that may result thereto. Accordingly, I fully acknowledge that there are risks that are not
possible to eliminate and therefore it is not the responsibility of Home Instead to eliminate such risks. Such
risks may include but are not limited to the risk of falling, wandering, overmedication and choking, all of which
may lead to serious injury or even death. I understand that if I want to have these risks significantly reduce, I
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have the option to request 2 caregivers to provide services which may reduce such risks or to seek alternative
arrangements.
Medical Emergency: In the event of a medical emergency while Home Instead personnel are present, I authorize
Home Instead to provide or obtain such medical treatment as they deem advisable under the circumstances
(including the use of a 911, EMS call (or to a hospice emergency line, as appropriate for each client)).
DNR (Do Not Resuscitate): I understand that it is my responsibility to provide Home Instead with a copy of any
Do Not Resuscitate order signed by my physician and any advance directive I may have
CPR: I acknowledge that Home Instead Senior Care staff are not trained to perform CPR. In case of respiratory
distress, chest pain, cardiac arrest, I acknowledge that the Home Instead staff will call 911 call (or to a hospice
emergency line, as appropriate for each client) and will follow any and all instructions prompted by the EMS
representative that picks up the phone. However, I acknowledge that this does not entail their being required to
perform CPR
Mutual Care Commitments. I acknowledge that - unless I specified in writing that Home Instead will not be
responsible for pre pouring medications, arranging doctor’s appointments, following up with doctors, ordering
food, handling financial matters for the Client.
Acknowledgement of Risks for any services provided in a adult care home or hospital. I fully acknowledge that
any services provided by Home Instead at any facility (any hospital, nursing home, assisted living facility,
independent living facility) are subject to certain legal restrictions. I have hired Home Instead to exclusively
provide custodial non-medical support for the Client as opposed to primary care or responsibility for taking
medications, personal care, ambulation, doctor’s appointments and general or specific health issues. 100%
responsibility for all such services lies exclusively in the hands of the adult care home or hospital in which Client
resides.
Termination of Services. I acknowledge that Home Instead may terminate services by providing 72 hour notice.
I fully acknowledge that I have read and fully understand this entire Agreement and that by signing below, I
agree with and accept all the terms and conditions contained herein. I further acknowledge and understand that
Provider is an independently owned and operated franchisee of Home Instead, Inc. and that Home Instead, Inc.:
(i) is not providing any of the Services under this Agreement; (ii) is not a party to this Agreement in any way; and
(iii) is in no way responsible for the acts or omissions of Provider or Provider’s employees.
If I am the Client’s authorized legal representative, I hereby acknowledge having reviewed all of this with Client
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Signature of Client (or Client’s authorized legal representative);
(if you are typing this out and emailing it, please type on the line above /S/ then your full name (Ex:
/S/ John Smith)
Relationship to Client:________________________Date:_____________
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FINANCIAL GUARANTY AGREEMENT
The undersigned, ____________________________________ (herein referred to as “Billing Party/
Guarantor”) wish to enter into this Financial Responsibility Agreement (the “Agreement”) with Home Care
Associates, Inc., (d/b/a an independently owned and operated Home Instead Senior Care franchise) (“Home
Instead”) to provide __________________________ (“Client”) with homecare services.
Guarantee. I acknowledge that Home Instead is relying upon my unconditional commitment to guarantee payment
for homecare services rendered to Client, irrespective of the Client’s ability to pay for the services.
PAYMENTS
I acknowledge my responsibility to make the following payments
Type of Charge
Rates for Services. Rates for Services are computed at time
and one half for the following 8 holidays: New Year's Day,
President’s Day, Easter Sunday, Memorial Day, Independence
Day, Labor Day, Thanksgiving Day, Christmas Day.
Minimum Hours
Weekdays: There is a minimum requirement of 5 hours per shift)
Week-ends: There is a minimum requirement of 8 hours per shift
Reimbursement of Expenses
Nursing Visits / Care Management
Amount
Hourly Rate: $21 per hour
Live-In Rate: $260 per day (flat rate) in case of
live-in. The conditions for a live in is that (i) room
and board is covered by the Senior and (ii) the
caregiver must be able to get a good night’s sleep
(otherwise they will not be productive to take
care of the client and so we would need to split
the shift into two 12 hour shifts which would be
charged at the hourly rate as detailed above).
Please note: if this is for more than 1 person
being cared for , an additional premium will be
applied depending upon how much work needs to
be done
If Home Instead makes payments on behalf of
Client (for example, for petty cash necessary for
the Client, for supplies for the Client, for
medications for the Client), such payments will be
added to the invoice at cost (no markup).
$250 per visit (or per hour of care management)
if nursing visits are required above and beyond
for supervision of the aides (for example, for
sick visits, for any type of nursing care or for
medication management) or for a field nurse to
accompany to a doctor’s appointment and/or
provide care management services with the
Client’s health care professionals/ family
members
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INVOICES
Are generated every 14 days, on Mondays, and they cover the 14 day
period that ends the Saturday prior to the Monday
Let’s try an example:
Hypothetical
Billing Period:
Sunday, 7th thru
Saturday, 20th
Hypothetical
Invoice is
Generated on:
Monday, 22th
HYPOTHETICAL
MONTH
S M T W T
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Live-In Caregivers: I acknowledge that I am being offered a discounted rate based on the following 3 conditions
(i) that I am providing sleeping accommodations (ii) 3 meals a day are being provided to the caregiver (meals are
to be reasonable and that what the Senior is eating unless the Senior is on a restricted diet) and (iii) the live-in
caregiver must be given the opportunity to get a reasonable amount of uninterrupted sleep at nighttime. If
these conditions are not met, we will not be able to provide a live in caregiver at the discounted rate and
alternative arrangements (such as two 12 hour shifts at the hourly rate) will need be provided. I acknowledge
that if meals are not provided, an additional $10 per day meal fee will be added to my invoice.
Incidental Expenses: I acknowledge that I am responsible for all expenses for incidental transportation
within the shift (ie – if and when the caregiver accompanies the Senior to the Senior’s activities and if
the caregiver accompanies the Senior to eat).
Changes in Schedule: I acknowledge that I can change the schedule at any time as long as I give Home Instead
48 hours prior notice (or I acknowledge that I will be charged for that shift even if I send the Home Instead
employee home early).
Cancellation: I acknowledge that I can cancel services at any time as long as I give Home Instead 72 hours
written notice (or 72 hours of service will be charged against deposit; the nursing assessment is not refundable).
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Assignment of Benefit: I hereby authorize payment directly to Home Instead Senior Care otherwise payable to
me for home health services provided under my nursing or home health benefits. I recognize that if irrespective
of the assignment of benefit under my long term care insurance policy, I am still responsibility for monies owed
to Home Instead for services rendered and if for any reason Home Instead Senior Care is not paid by the long
term care insurance policy, I assume 100% responsibility for services rendered and will pay Home Instead Senior
Care any amount not paid by the long term insurance care carrier
Email PDF versions of the invoices. To what email address should we e-mail invoice to?___________________
Non-Solicitation of Home Instead Senior Care Employees. I (or any affiliate of mine or the Client) agree not to
engage, hire, employ or socially visit with any of Home Instead‘s employees while this Agreement is in effect and
continuing for a period of one (1) year after the termination of this Agreement, unless I receive Home Instead’s
approval and pay Home Instead a referral fee in an amount equal to the greater of 2 months of service or $5,000
per employee. I agree that any breach of this agreement will cause Home Instead substantial and irrevocable
damage.
_________________________________________________________________
Signature of Billing Party/ Guarantor
(if you are typing this out and emailing it, please type on the line above /S/ then your full name (Ex:
/S/ John Smith)
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AUTOMATIC BANK WITHDRAWALS (DIRECT DEBIT)
(we can automatically charge your bank account; you will receive detailed invoices)
Name of Client
Name of Bank
Exact Name of Person on
the Account
Checking or Savings?
Is this a Checking or Savings account? Check one: [ ] Checking account [ ] Savings account
Routing # of the Bank (see
the model check below to
see how you can determine
the Routing #)
Account # of the Bank (see
the model check below to
see how you can determine
the Account #)
Authorization Statement
I hereby authorize Home Instead Senior Care, to initiate debit entries to my account at the
depository financial institution named below, and to debit the same to such account. I
acknowledge that the origination of ACH transactions to my account must comply with the
provisions of the U.S. law.
Signature
This authorization is to remain in full force and effect until Home Instead has received
written notification from me (or either of us) of its termination in such time and in such
manner as to afford my bank a reasonable opportunity to act on it. Home Instead will only
charge for services rendered at the specific rates agreed to and authorized by Client in the
executed financial agreement
(if you are typing this out and
emailing it, please type on the line
above /S/ then your full name (Ex:
/S/ John Smith)
EXAMPLE OF A CHECK SO YOU CAN DETERMINE HOW TO FIND ROUTING AND ACCOUNTING NUMBER
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BILL OF RIGHTS AND RESPONSIBILITIES
I. BILL OF RIGHTS
As a patient of Home Instead Senior Care you have the right to:
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Be informed of your rights both verbally & in writing at time of admission & prior to
initiation of care.
Receive competent, individualized care and service from Home Instead Senior Care
staff regardless of age, race, color, national origin, religion, sex, disease, disability or
any other category protected by law or decisions regarding advance directives.
Be treated with dignity, courtesy, consideration, respect and have your property
treated with respect.
Be informed verbally and in writing of the services available and related charges, as
they apply to the primary insurance, other payers, and self-pay coverage before care is
initiated. To be informed of any changes in the sources of payment and your financial
responsibility as soon as possible but no later than thirty (30) calendar days after Home
Instead Senior Care, becomes aware of the change.
Be informed both orally and in writing, in advance of the Plan of Care, of any changes in
the Plan of Care, and to be included in the planning of care before treatment begins; be
informed of all treatment prescribed, when and how services will be provided, and the
names and functions of any person and affiliated program providing care and services,
including photo identification of agency staff and participate in the development of the
discharge plan.
Participate in the planning of your care and be advised in advance of any changes to the
plan of care.
Refuse care and treatment after being fully informed of and understanding the
consequences of such actions and to initiate an Advance Directive, “Living Will”, durable
power of attorney and other directives about your care consistent with applicable law
and regulations. Refuse to participate in research or experimental treatment.
To appropriate assessment of pain and management of his/her pain.
Receive information regarding community resources and to be informed of any financial
relationships between Home Instead Senior Care and other providers to which you may
be referred to by the agency.
Be informed of the procedures for submitting patient complaints, voice complaints and
recommend changes in the policies and services to Director of Patient Services by
calling the following telephone number: 212-614-8057. The expression of such
complaints by the patient shall be free from interference, coercion, discrimination or
reprisal.
If dissatisfied with the outcome, you may also submit the complaint to the NYS
Department of Health or any outside representative of the patient’s choice.
NYS Department of Health
Metropolitan Regional Office
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New York, New York
212-417-5888
The expression of such complaints by the client or client designee shall be free from
interference, coercion, discrimination or reprisal.
11. Express complaints about the care and services provided or not provided and complaints
concerning lack of respect for property by personnel furnishing services on behalf of
Home Instead Senior Care, and to expect the agency to investigate such complaints
within 15 days of receipt of complaint. Also, if dissatisfied with the outcome, may
submit an appeal to the agency’s governing authority which will be reviewed within 30
days of receipt of appeal request.
12. Receive timely notice of impending discharge or transfer to another agency or to a
different level of care and to be advised of the consequences and alternatives to such
transfers.
13. Privacy, including confidential treatment of records and access to your records on
request. Information will not be released without your written consent except for
those instances required by law, regulation or third party reimbursement.
14. In the situation when the patient lacks capacity to exercise these rights, the rights
shall be exercised by an individual, guardian or entity legally authorized to represent
the patient.
If I am signing this on behalf of the Client as their authorized legal representative, I
hereby acknowledge (i) having authorization to sign on their behalf and (ii) having reviewed
all of this with Client
_________________________________________________________________
Signature of Client (or Client’s authorized legal representative);
(if you are typing this out and emailing it, please type on the line above /S/ then your full name (Ex:
/S/ John Smith)
Date:_____________
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BILL OF RIGHTS AND RESPONSIBILITIES
II. BILL OF RESPONSIBILITIES
As a Home Care Client, you have the responsibility to:
- Be seen by a doctor on a regular and ongoing basis.
- Share complete and accurate health information.
- Be responsible for following the treatment plan recommended by your physician.
- Make it known if you do not understand or cannot follow the treatment plan.
- Cooperate with agency staff and not discriminate against staff.
- Notify the agency in advance when you cannot keep a scheduled appointment
- Notify the agency in the event of change in your health status.
- Be responsible for your actions if you refuse treatment or do not follow the
agency’s recommendations/directions.
- Allow Home Instead caregiver use of your telephone to call the agency at
beginning and end of shifts
- Allow Home Instead staff to use photograph and video in the home in order to
record any observations regarding the client’s safety, health or wellbeing or for
purposes of supervising and recording the Home Instead caregivers’ skills and
compliance with agency policy
- Maintain a home environment that facilitates effective home care
- Home Safety Evaluation: allow Home Instead to conduct home safety evaluations
and assessments
- Fall Risks: unless Home Instead Senior Care is instructed by you, your
representative or health care professional to be at your side at all times during
the shifts covered by Home Instead Senior Care so as to avoid a fall from
occurring, Home Instead Senior CAREGivers will provide homecare tasks
covering meal preparation, light housekeeping, shopping errands, medication
reminders and other tasks, many of which may entail leaving your side.
Accordingly, it is possible that you may fall during the shift. If you are
concerned about this risk, please call (or have your representative or health
care physician call) 212-614-8057 and make this request clear.
- Medications (*):
„ Home Instead CAREGivers can give medication reminders (see definition
below for Medication Reminder). Home Instead CAREGivers cannot
administer medications (see definition below for Medication
Administration).
„ Medication Administration includes pouring medications into pre pour
trays, and administering injections and reading INR/ blood sugar levels.
Home Instead CAREGivers cannot do this. If you want assistance in pre
pouring medications into pill organizers, our Registered Nurse would be
more than happy to help you with this
„ Medication Reminders entail a simple reminder to the senior that it is time
to take the medication. Assistance with opening the pre pour tray is
permissible under NY State law.
„ If you have any questions as to which activities entail medication
administration as opposed to medication reminder, please call us at 212-
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614-8057 or notify the Home Instead Senior Care nurse, who can
administer your medications, for a fee (call 212-614-8057)
Keys (*): Home Instead Senior Care staff is not permitted to accept keys to
your home unless a signed permission for management of keys is obtained from
you (see attached Key Form).
Gifts (*): I understand that Home Instead Senior Care staff is not permitted
to accept gifts unless a signed authorization is obtained by me and given to
Home Instead.
Meal Expenses: I understand that live-out CAREGivers are expected to bring
their meals. However, if I desire that the CAREGiver accompany me to a diner or
other venue, I will cover the CAREGiver’s expenses.
Valuables: I agree to use a common sense approach to the handling of valuable
items and money while the Agency provides service in my home, I agree to
remove from the home or place in an inaccessible location any irreplaceable
items including cash, jewelry, sliver or other valuables.
Here is a comprehensive list of my valuables (defined as any piece of nonfurniture that is worth $500 or more) that I cannot place in an inaccessible
location
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Finances(*): I understand that Home Instead Senior Care staff is not
permitted to help me with banking, writing checks or using my bankcards. I also
understand that any Home Instead employee will be immediately terminated and
reported to the police should they ever use any of my bankcards (even if done at
my request). I understand that asking a Home Instead Senior Care staff to
assist me in this respect will compromise them significantly. If you need
assistance in this area, please call our office at 212-614-8057 and our
administrative personnel can assist you
If I am signing this on behalf of the Client as their authorized legal representative, I
hereby acknowledge (i) having authorization to sign on their behalf and (ii) having reviewed
all of this with Client
Signature of Client (or Client’s authorized legal representative); (if you are typing this out
and emailing it, please type on the line above /S/ then your full name (Ex:
/S/ John Smith)
Date:_____________
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