Client Family Folder

CLIENT FAMILY FOLDER — SERVICE AGREEMENT

Identifying Information

Client Name:    Date of Birth:

Family Members & Household

Household/Family ID Number:

Emergency Contacts

Medical & Safety Information

Referral & Intake

Referral Source:    Intake Date:

WHEREAS Recitals

WHEREAS, Client Name: has requested ongoing family-centered services and document management maintained by Provider Name: ; and

WHEREAS, Provider maintains case records, service plans, and communications in a structured Family Folder to support coordinated care and to meet the administrative, medical, and legal needs of the family; and

WHEREAS, the parties desire to document the scope, retention, confidentiality, and financial terms governing the services and the Family Folder records pursuant to the terms set forth in this Agreement.

Scope of Work

Provider will create, maintain, and make accessible a Client Family Folder containing, at minimum: identification documents, medical and immunization records, service plans, signed consents and releases, referral histories, contact logs, and case notes. Provider will also coordinate scheduled family conferences, referrals to third-party service providers, and timely updates to the Family Folder as services are provided.

Payment Terms

The Client shall pay Provider for services related to the Family Folder in accordance with the following terms.

Term and Termination

This Agreement commences on Start Date: and continues until End Date: , unless earlier terminated pursuant to this section.

Either party may terminate this Agreement for any reason upon written notice to the other party no fewer than days. Upon termination Provider shall: (a) provide an accounting of services performed and amounts due; (b) return or transfer Family Folder records as directed in writing by the Client, subject to lawful retention obligations; and (c) securely dispose of copies of records beyond the retention period specified below.

Record Retention & Confidentiality

Provider acknowledges that Family Folder contents contain personal, health and other sensitive information. Provider shall maintain reasonable administrative, technical, and physical safeguards to protect such information from unauthorized disclosure. Provider shall not disclose Family Folder information except: (a) with prior written consent of the Client; (b) as required by court order or applicable law; or (c) to contracted third-party service providers bound by written confidentiality obligations at least as protective as those in this Agreement.

Provider will retain records for a minimum retention period of years following case closure unless otherwise required by law. After the retention period Provider will destroy or permanently de-identify records in a secure manner and provide written confirmation of destruction upon Client request.

Disclosure and Authorized Representatives

Client may designate authorized representatives permitted to access the Family Folder by completing and signing written authorization on file with Provider. Provider will rely on such authorizations until revoked in writing. Disclosures to authorized representatives will be limited to the minimum information necessary to fulfill the authorized purpose.

Governing Law

This Agreement shall be governed by and construed in accordance with the laws of the State of without regard to conflict-of-law principles.

Indemnification

Each party agrees to indemnify and hold harmless the other party from and against any claims, liabilities, losses, or expenses arising out of a breach of this Agreement or the negligent or willful acts of the indemnifying party, except to the extent caused by the indemnitee's own negligence or willful misconduct.

Entire Agreement

This Agreement, including attachments and records created in the Client Family Folder pursuant to it, constitutes the entire agreement between the parties with respect to its subject matter and supersedes all prior and contemporaneous agreements and understandings, whether written or oral. Any amendment or modification must be in writing and signed by both parties.

Documents Checklist

The following documents are included in the Family Folder (check all that apply):

Identification copy
Birth certificate(s)
Insurance / Medicaid information
Medical / immunization records
Signed consents & releases
Guardianship / custody paperwork
Other (describe below)

Case Notes & Services Provided

Acknowledgement

By signing below the parties acknowledge receipt of a copy of this Agreement and confirm that the information recorded in this Client Family Folder is accurate to the best of their knowledge. The Client authorizes Provider to maintain the Family Folder and to act in accordance with the access and disclosure terms set forth herein.

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