Client Service Agreement

Step 1 of 3

Client Information
Name*
First Last
Email*
Phone*
Address*
Street Address Address Line 2 City State ZIP Code
Date of Birth*
MM slash DD slash YYYY
Primary Family Caregiver*

Emergency Contacts*

Should be someone who doesn't live in the same household as the client

Name	Phone	Email	Address	Relationship to the client

Physician Information*

Name	Phone	Email	Address	Physician Type

Consent
Services provided by Life Foundation Home Care are billed on an hourly or daily basis (hourly times are billable in fifteen minutes increment). Any miles accrued while providing client service will be billed at the current Federal mileage rate (currently $0.58, subject to change). When caregivers are on duty during meal times, we ask, when it is appropriate, their meal be included. Charges for service rendered are invoiced twice a month based on plan of care. Invoice will be e-mailed to the responsible party. Payments are due upon receipt. Returned checks will incur a processing fee of $35. Payments made 5 days after due date will incur a $35 late fee charge and 3% of the unpaid balance for each month that the payment is overdue. I authorize Life Foundation Home Care to bill for services provided to me.
I agree to the billing policy
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Terms of Service*
Following are the Terms of Service.

Life Foundation Home Care shall provide home care services according to the careplan.

SERVICE CHANGES: Changes in services provided must be discussed with our office as well as the caregivers. This includes changes in days or numbers of hours scheduled as well as changes in the duties performed by the caregivers. Life Foundation Home Care will do its best to provide a replacement caregiver if the designated client caregiver is unavailable. However, there could be a possibility that the client family may have to provide temporary support in the event Life Foundation Home Care cannot find an immediate replacement caregiver.

EMPLOYEE RECRUITING/HIRING: Our employees cannot work directly for you. All services are provided through Life Foundation Home Care. Client will take no steps to recruit as its own employees those Caregivers provided by Life Foundation Home Care during the term of this Agreement. Client understands Life Foundation Home Care is not an employment agency and that its employees are assigned to the client to render temporary service and are not assigned to become employed by the client. The client further acknowledges the considerable expense incurred by the Life Foundation Home Care to advertise, recruit, interview, evaluate, reference check, and supervise its employees. In recognition of the substantial efforts made by Life Foundation Home Care in providing quality staff to Client, in the event that the Client employs or retains as a contractor any Life Foundation Home Care employee provided to the Client at any time within twenty four (24) months of ending such employment/retention by the Client, the Client agrees to paying Life Foundation Home Care a placement fee equal to twenty five percent (25%) of the employee's total annual compensation as per the amount a full-time employee with Life Foundation Home Care is paid annually. This provision shall survive termination of this Agreement.

HOLIDAYS: Our staff is not always available to work on holidays. If arrangements are made for work on a holiday, you will be billed at time and a half of your regular rate. (Holidays: New Year’s Eve, New Year’s Day, Thanksgiving, Christmas Eve, Christmas Day).

CANCELING APPOINTMENTS: You will be billed a minimum of 4 hours of your scheduled time for appointments cancelled with less than 24 hours notice.

SERVICE CANCELLATION: This agreement shall continue until terminated by either party. Service can be terminated at any time. We appreciate at least 24hrs notice, however, so we can inform the caregiver.

CONSENT FOR CARE: Client consents to receive care and services from Life Foundation Home Care, in accordance with the care plan developed with my input and consent and based on client needs.

AUTHORIZATION TO RELEASE INFORMATION: I consent to the release of information and/or disclosure by and to Life Foundation Home Care to individuals acting in official capacities as client advocate, representing governmental or third party payers or health care providers involved in client's care.

CLIENT TRANSPORTATION: It is understood that if client agrees to be a passenger in Life Foundation Home Care employee personal vehicle, or any other form of public/private transportation vehicle, they do so at their own personal risk and will not hold Life Foundation Home Care responsible or liable for any damages incurred while riding as a passenger in said vehicles.

CLIENT TRANSPORTATION IN OWN VEHICLE: I release Life Foundation Home Care from any liability or damages while being transported by the assigned caregiver in my own personal vehicle. I take responsibility of maintaining the insurance on the vehicle. I give permission for the caregiver assigned to me by Life Foundation Home Care to transport me in my personal vehicle.
I understand and agree to the Terms of Service.

Client Service Agreement

Step 1 of 3

Client Information

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