Healthcare Assisted Living Agreement

HEALTHCARE ASSISTED LIVING AGREEMENT

Parties and Effective Date

This Assisted Living Agreement (the Agreement) is entered into between Facility Name: located at Facility Address: and Resident Name: .

Effective Date of Admission:

Resident Information

Insurance and Billing

Services, Care Plan and Assessments

Facility agrees to provide assisted living services including personal assistance with activities of daily living, medication administration consistent with physician orders, routine monitoring, housekeeping, meals, and social activities as specified in the individualized Care Plan prepared after admission assessment.

Resident agrees to participate in assessments and to comply with the Care Plan. Facility will review the Care Plan at least every 90 days or upon significant change in condition.

Medical History and Medications

Resident authorizes Facility staff to administer medications in accordance with the Care Plan and physician orders.

Fees, Payment and Refunds

Monthly Fee (including described services): $ . Security Deposit: $ . Fees are payable in advance on the first day of each month. Late charges, returned check fees, and other penalties are due as set forth below.

Resident Rights and Responsibilities

Resident retains all rights afforded by law. Resident agrees to comply with Facility policies, to treat staff and other residents with respect, and to promptly report changes in health status. Facility will provide written notice of any material policy changes and will maintain resident confidentiality consistent with privacy laws.

Termination and Discharge

Either party may terminate this Agreement with written notice. Facility may give immediate notice and initiate discharge for nonpayment, danger to resident or others, material breach of Facility policies, or when it can no longer meet the resident's needs. Resident shall provide at least days' written notice for voluntary termination, unless otherwise agreed in writing.

Liability, Indemnification and Insurance

Facility will exercise reasonable care in providing services. Resident releases Facility from liability for ordinary negligence to the extent permitted by law, and agrees to indemnify Facility for claims arising from Resident's breach of this Agreement or intentional acts. Resident is encouraged to maintain personal health and property insurance; Facility's insurance is primary only as required by applicable law.

Privacy, Records and Authorization

Facility maintains health records and protected health information in accordance with applicable privacy laws. By signing, Resident acknowledges receipt of the Facility's Notice of Privacy Practices and authorizes Facility to disclose health information to the persons and providers necessary for care, billing, and emergency response as identified below.

Emergency Medical Treatment

In the event of a medical emergency, Facility will notify emergency services and the emergency contact. If immediate treatment is required and next of kin or physician cannot be reached, Resident authorizes Facility to obtain emergency medical care and to transfer Resident to an appropriate medical facility.

Dispute Resolution and Governing Law

The parties agree that disputes arising under this Agreement shall be resolved first by good faith negotiation. If unresolved, disputes will be submitted to binding arbitration in the county where the Facility is located, to the extent permitted by law. This Agreement shall be governed by the laws of the State of .

Miscellaneous

This Agreement constitutes the entire understanding between the parties concerning the subject matter herein and supersedes prior oral or written agreements. Any amendment must be in writing and signed by both parties. If any provision is held invalid, the remaining provisions remain effective.

Acknowledgement and Certifications

By signing below, Resident certifies that the information provided in this Agreement is true and accurate to the best of Resident's knowledge, that Resident has had the opportunity to ask questions and receives a copy of this Agreement, and that Resident consents to the terms and services described above.

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