Healthcare Care Home Agreement

HEALTHCARE CARE HOME AGREEMENT

This Healthcare Care Home Agreement (Agreement) is entered into between Care Home Name: with principal address (Provider), and Resident Name: , Date of Birth: . Effective Date: .

1. Admission and Assessment

Admission is conditioned upon completion of an initial assessment and development of an individualized care plan. Primary Care Physician: , Phone: .

2. Services Provided

Provider will furnish the following services as set forth in the individualized care plan. Resident acknowledges that services will be provided in accordance with state licensing and Provider policy. Select applicable services:

Personal care and assistance with activities of daily living
Medication administration and management
Meal provision and dietary accommodations
Light housekeeping and laundry
Transportation for medical appointments (as available)

3. Fees, Billing, and Payment

Resident agrees to pay Provider fees for services. Monthly Fee:

Payment is due by day of each month. Late payment will incur a late fee of of the unpaid balance or the maximum allowed by law.

4. Insurance and Third-Party Payments

5. Resident Medical Information

6. Individualized Care Plan

Provider will prepare and implement an individualized care plan based on the assessment. Resident shall participate in periodic reviews and agrees that the care plan may be modified to address changing needs. Summary of initial care goals:

7. Medication Administration and Consent

Provider will administer medications in accordance with the resident's medication orders. By signing this Agreement, Resident provides consent for Provider staff to administer prescribed medications and to contact prescribing clinicians as necessary.

Resident consents to medication administration by Provider staff

8. Personal Property and Valuables

Provider is not liable for loss or damage to personal property except to the extent caused by Provider's gross negligence. Resident is encouraged to maintain an inventory of personal items and to secure valuables.

I acknowledge receipt of Provider's personal property policy and understand Provider's limited liability

9. Privacy, Records, and HIPAA Authorization

Provider maintains confidentiality of protected health information in accordance with applicable law. Resident acknowledges receipt of Provider's Notice of Privacy Practices and authorizes Provider to obtain and release medical information for care, payment, and health care operations.

Resident acknowledges receipt of Notice of Privacy Practices

10. Emergency Treatment and Transportation

In the event of an emergency, Provider is authorized to obtain medical treatment and arrange transportation to the nearest appropriate facility. Provider will attempt to notify the emergency contact as soon as practicable.

Resident consents to emergency medical treatment and transportation

11. Term, Termination, and Discharge

This Agreement continues until terminated by either party. Provider may terminate for cause or when Resident's needs exceed Provider's ability to provide services. Either party may terminate with days' written notice, except as required by law.

12. Liability and Indemnification

To the fullest extent permitted by law, Resident releases Provider from liability for loss, damage, or injury except where caused by Provider's gross negligence or willful misconduct. Resident agrees to indemnify and hold Provider harmless from claims arising from Resident's negligence or intentional acts.

13. Governing Law and Dispute Resolution

This Agreement shall be governed by the laws of the state in which the Provider operates. Parties agree to attempt informal resolution of disputes. If unresolved, disputes shall be submitted to binding arbitration unless prohibited by law.

Resident agrees to binding arbitration for disputes arising under this Agreement

14. Miscellaneous Provisions

This Agreement constitutes the entire agreement between the parties and supersedes prior oral or written agreements. Amendments must be in writing and signed by both parties. If any provision is held invalid, the remainder shall remain in effect.

15. Acknowledgment and Acceptance

By signing below, the parties acknowledge that they have read, understand, and agree to the terms and conditions of this Agreement, and that the information provided in this form is true and accurate to the best of their knowledge.

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