Healthcare Hygiene Contract

HEALTHCARE HYGIENE CONTRACT

This Healthcare Hygiene Contract ("Contract") is entered into by and between the parties identified below for the provision of personal hygiene services, infection prevention measures, and related supportive care. Provider and Client agree to the terms set forth herein.

PARTIES AND CONTACT INFORMATION

Date of Birth:    Gender:    Phone:

INSURANCE INFORMATION

Policy Number:    Group Number:    Subscriber Name:

MEDICAL HISTORY & CURRENT STATUS

Ambulation status (select as appropriate): Ambulates independently Uses assistive device Bedbound

SCOPE OF HYGIENE SERVICES

Provider shall perform the following hygiene services as selected and agreed. Provider represents that services will be performed by personnel trained in infection prevention and in accordance with accepted clinical practice.

Assisted bathing/shower
Oral hygiene/denture care
Grooming (hair care, shaving, nails)
Perineal and incontinence care
Skin assessment and basic skin care
Assistance with dressing
Toileting assistance / catheter care (non-invasive)
Basic wound dressing assistance (as ordered by provider)
Other services:

Frequency and Schedule: Services will be provided on the following schedule:

PROVIDER OBLIGATIONS AND STANDARDS

Provider shall: (a) maintain personnel trained in hygiene care; (b) comply with applicable infection control and standard precautions; (c) use appropriate personal protective equipment (PPE) when indicated; (d) document services rendered in a clinical record; and (e) promptly notify Client or Client's representative of any unusual incident, skin breakdown, suspected infection, or decline in condition.

Provider affirms it carries professional and general liability insurance in amounts reasonable for the services provided and shall provide proof of insurance upon written request.

Provider will follow standard precautions and use PPE where clinically indicated.

CLIENT RESPONSIBILITIES

Client or Client's representative shall: (a) provide accurate medical and allergy information; (b) notify Provider of any change in condition or new orders from the treating clinician; (c) ensure safe access to the area of care and necessary supplies; and (d) cooperate with care staff. Client is responsible for providing transportable medical supplies specifically required for certain services unless otherwise agreed.

FEES, BILLING, AND PAYMENT

Fee per visit / unit: $. Billing frequency: .

Payment responsibility: Bill insurance Client responsible for copayment/fees Other arrangement

Client agrees to timely payment of any amounts not covered by insurance, and to reimburse Provider for costs of missed-visit charges if visits are not canceled within the agreed notice period.

TERM, TERMINATION, AND CANCELLATION

Term Commencement Date: . This Contract shall continue until terminated by either party upon written notice.

Termination: Either party may terminate for convenience with days' advance written notice. Provider may terminate immediately for client nonpayment or if actions by Client place staff at risk.

LIABILITY, INDEMNIFICATION, AND LIMITATIONS

Provider will exercise reasonable care in performing services. To the fullest extent permitted by law, Client agrees to indemnify and hold harmless Provider from claims arising from Client's failure to disclose material medical information, from Client's negligence, or from conditions at the site that create an unsafe environment. Provider's liability for direct damages arising from breach of this Contract is limited to actual monetary damages not to exceed the total fees paid to Provider under this Contract in the preceding six months. In no event shall Provider be liable for consequential, special, or punitive damages.

HIPAA / PRIVACY AUTHORIZATION & ACKNOWLEDGMENT

Client acknowledges that Provider maintains protected health information and has privacy practices. By signing below, Client authorizes Provider to use and disclose protected health information as necessary for treatment, payment, and healthcare operations in accordance with applicable law, and consents to electronic and/or written communication as clinically appropriate.

I acknowledge receipt of Provider's privacy practices and authorize use and disclosure of my protected health information for treatment, payment, and operations.

RISKS, BENEFITS, AND CONSENT

Client understands the benefits of professional hygiene assistance include improved cleanliness, skin integrity support, and reduced infection risk. Client acknowledges potential risks including slips/falls during transfer, skin irritation, allergic reaction to products, and inadvertent exposure of wounds. Provider will take reasonable measures to mitigate these risks.

I consent to the hygiene services described in this Contract and understand that I may withdraw consent at any time by providing written notice to Provider, subject to the termination provisions of this Contract.

NOTICES

MISCELLANEOUS

This Contract constitutes the entire agreement between the parties with respect to the subject matter herein and supersedes prior agreements. This Contract may be amended only in writing signed by both parties. If any provision is held invalid, the remaining provisions shall remain in force. This Contract shall be governed by the laws of the jurisdiction where services are primarily performed.

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