Healthcare Care Homes Agreement

HEALTHCARE CARE HOMES AGREEMENT

Parties and Admission

This Agreement is made between Care Home Name: with principal address: (hereinafter "Provider"), and Resident Name: , Date of Birth: (hereinafter "Resident").

Resident Information

Insurance and Billing

Monthly Fee (room and board): $. Security Deposit: $. Billing Cycle: . Additional charges for specialized care, therapy, or supplies will be billed as incurred.

Scope of Services

Provider will furnish the following services as required by Resident's assessed needs: room and board, routine personal care, medication administration according to Provider policies and prescriber orders, assistance with activities of daily living, routine nursing oversight, housekeeping, laundry, meals and dietary accommodations, social and recreational programs, and care coordination. Specialized medical services are not included unless expressly agreed in writing.

Medical History and Medications

Consent to Treatment and Medication

Resident hereby authorizes Provider and its agents to provide routine and emergency medical care deemed necessary by Provider's clinical staff, to administer medications pursuant to prescriber orders, and to arrange for transport to medical facilities when required. Resident acknowledges that Provider will not be responsible for experimental treatments unless expressly consented to in writing.

Resident consents to medication administration by licensed staff: Yes I decline administration (Resident acknowledges responsibility to arrange alternatives)

Privacy and Authorization

Resident acknowledges receipt of Provider's Notice of Privacy Practices and authorizes Provider to disclose protected health information to the following persons for purposes of care coordination and billing: Name: Relationship: Phone: .

Authorization Expiration Date: . This authorization may be revoked in writing except to the extent that action has already been taken.

Fees, Payment Terms and Refunds

Charges are due in accordance with Provider's billing schedule. Late payments may be subject to finance charges and/or termination of residency. Deposits are refundable in accordance with Provider's deposit policy less deductions for unpaid charges and damages. Final charges will be prorated through the date of discharge.

Termination and Discharge

Either party may terminate this Agreement upon written notice as required by Provider policy. Provider may discharge Resident immediately for reasons including but not limited to: material nonpayment, danger to others or self, material breach of house rules after notice, or changes in medical needs beyond Provider's capabilities. Resident agrees to vacate premises on the date of discharge and to cooperate with Provider in transfer planning.

Liability, Insurance and Indemnity

Provider carries liability insurance customary for its operations. Provider is not responsible for loss of Resident's personal property except when caused by Provider's gross negligence. Resident and Responsible Party agree to indemnify and hold Provider harmless from claims arising from Resident's conduct, negligence, or breach of this Agreement, except to the extent of Provider's gross negligence or willful misconduct.

Dispute Resolution and Governing Law

The parties agree that disputes arising under this Agreement shall be resolved first through good-faith negotiation, then through mediation. If unresolved, disputes shall be submitted to binding arbitration consistent with applicable law. This Agreement shall be governed by the laws of the state where Provider is located.

Miscellaneous Provisions

This Agreement constitutes the entire agreement between the parties with respect to its subject matter. Any amendment must be in writing and signed by both parties. If any provision is held invalid, the remaining provisions shall remain in full force.

Acknowledgment

By signing below, Resident and Provider acknowledge that they have read and understand the terms of this Agreement, that Resident has had the opportunity to ask questions and receive answers, and that a copy of this Agreement has been provided to Resident.

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