Case Management Form

CASE MANAGEMENT FORM

Parties and Recitals

WHEREAS, Client Name: and Agency/Provider Name: enter into this Case Management Form to document assessment, services, and the mutual obligations of the parties.

WHEREAS, the parties intend that the services described in this Form be provided to address the Client's identified needs and goals, and that both Client and Provider will cooperate in the planning and delivery of services consistent with applicable standards of care.

WHEREAS, the parties acknowledge that information provided in this Form will be used to develop and implement a case management plan and that the Client's informed consent is required for service provision and limited information sharing as set forth below.

Administrative Information

Client Identifying Information

Assessment, Needs, and Goals

Scope of Work and Service Plan

The Provider shall perform case management services as described below. Services shall include coordination of care, assessment, linkage to community resources, advocacy, monitoring of progress, and documentation. Services do not include diagnostic mental health treatment unless specifically stated.

Payment Terms

The Client agrees to the following payment terms for any fee-based services provided by the Provider. If the Provider is funded by public or third-party payors, those arrangements prevail for covered services; the Client remains responsible for any non-covered fees as set forth below.

Late Payment Fee: . Client will be responsible for reasonable collection costs and any returned check fees.

Term and Termination

Term Start Date:   Anticipated End Date:

Either party may terminate services for convenience with prior written notice to the other party. Required Notice Period: days. Provider may terminate immediately for failure to pay, for client conduct that endangers staff or others, or for other material breaches after reasonable efforts to resolve the issue.

Confidentiality and Information Sharing

All client records and communications are confidential and will be maintained in accordance with applicable law. Client authorizes the Provider to exchange information that is necessary to provide services and to coordinate care with authorized persons or agencies listed below. Client understands the following exceptions to confidentiality: duty to report abuse or neglect, imminent risk of harm to self or others, court-ordered disclosure, and other disclosures as required by law.

By signing below, the Client provides informed consent to the exchange of information with authorized recipients as necessary to implement the service plan, subject to the limitations set forth above and any additional limits specified in writing by the Client.

Governing Law; Entire Agreement

This Form shall be governed by the laws of the State of without regard to its choice-of-law rules. This Form, together with any attachments and the service plan, constitutes the entire agreement between the parties with respect to the subject matter herein and supersedes all prior agreements and understandings, whether written or oral.

Representations, Certifications, and Notices

The Client represents that all information provided in this Form is true and complete to the best of the Client's knowledge. The Client certifies that they have read and understand the terms of this Form, have had the opportunity to ask questions, and consent to receive case management services under these terms.

Mandatory Reporting Notice: Provider is required by law to report suspected abuse, neglect, or exploitation of vulnerable persons to the appropriate authorities. Such reports may be made without the Client's consent.

Provider Assignment / Case Manager

Acknowledgment and Consent

By signing below, the Client acknowledges receipt of a copy of this Case Management Form, consents to the services and information-sharing described herein, and understands their rights and responsibilities including the right to revoke consent in writing except to the extent that action has already been taken in reliance on this consent.

If the Client is a minor or otherwise legally represented, the signatory also affirms authority to consent on behalf of the Client and will provide documentation of such authority upon request.

Sign Now