Healthcare Living Agreement

HEALTHCARE LIVING AGREEMENT

This Healthcare Living Agreement ("Agreement") is entered into by the parties identified below for the provision of residential accommodation and associated healthcare services. Resident Name: Provider/Facility Name:

1. TERM AND ADMISSION

Admission Date: This Agreement begins on the Admission Date above and continues until terminated pursuant to Section 10 below. Resident is admitted for the purpose of receiving residence and the healthcare services described in this Agreement.

2. RESIDENT INFORMATION

3. EMERGENCY CONTACT

4. INSURANCE AND BILLING

5. MEDICAL HISTORY

6. SERVICES TO BE PROVIDED

The Provider agrees to furnish the following services as indicated. Resident acknowledges that services are provided according to an individualized care plan developed by Provider and Resident's clinical team.

Assistance with activities of daily living (ADLs) such as bathing, dressing, toileting

Medication administration and monitoring

Meal preparation and dietary support

Basic housekeeping and laundry services

Skilled nursing services as ordered by physician

7. MEDICATIONS AND TREATMENT CONSENT

Resident hereby consents to the administration of medications, routine treatments, and non-invasive procedures as ordered by Resident's treating physician and carried out by Provider staff. Resident authorizes the Provider to consult with Resident's prescribing practitioners and to obtain and maintain medication and treatment records.

Resident acknowledges risks associated with medication administration, including but not limited to adverse drug reactions, interactions, and allergic responses. Resident agrees to promptly report new symptoms and to participate in medication reconciliation as requested by Provider.

I consent to medication administration and routine medical treatment as described above.

8. EMERGENCY MEDICAL CARE

In the event of a medical emergency, Provider is authorized to arrange for emergency medical treatment and transportation to an appropriate medical facility. Reasonable efforts will be made to notify the emergency contact listed above prior to or immediately following transfer. Resident consents to emergency care and understands that costs of emergency services may be billed separately.

9. PAYMENT, FEES, AND FINANCIAL RESPONSIBILITY

Monthly Fee: Additional skilled or third-party professional services not included in the Monthly Fee will be billed to Resident or Resident's insurer. Resident is responsible for co-payments, deductibles, and any services not covered by insurance.

Failure to timely pay agreed fees may result in termination of services in accordance with Section 10 below.

10. TERMINATION AND TRANSFER

Either party may terminate this Agreement with written notice in accordance with Provider policy and applicable law. Provider may transfer or discharge Resident for medical reasons, safety concerns, non-payment, or material breach. Resident retains the right to leave the facility at any time, subject to applicable discharge planning and payment obligations.

11. CONFIDENTIALITY AND HIPAA ACKNOWLEDGMENT

Provider will maintain the confidentiality of Resident's protected health information in accordance with applicable privacy laws. By signing below, Resident acknowledges receipt of the Provider's privacy practices and authorizes Provider to use and disclose health information for treatment, payment, and healthcare operations as described in those practices.

I acknowledge receipt of the Provider's privacy practices and authorize use and disclosure as described.

12. AUTHORIZATION TO OBTAIN MEDICAL RECORDS

Resident authorizes the release of medical records to Provider as necessary to coordinate care. This authorization expires on: unless earlier revoked in writing.

13. LIABILITY, RELEASE, AND INDEMNIFICATION

Provider will exercise reasonable care in providing services. Except to the extent prohibited by law, Resident agrees to release and hold Provider harmless from liability for injury or loss arising from the provision of services, except for gross negligence or willful misconduct by Provider. Resident agrees to indemnify Provider for claims arising from Resident's acts or omissions.

14. RIGHTS, ADVANCED DIRECTIVES, AND WITHDRAWAL

Resident retains the right to participate in care planning, voice grievances, and execute advance directives. Does Resident have an advance directive on file? Yes No

Resident may withdraw consent to services at any time by providing written notice; withdrawal does not relieve Resident of financial obligations for services already rendered.

15. GOVERNING LAW AND DISPUTE RESOLUTION

This Agreement is governed by applicable law. The parties agree to attempt informal resolution of disputes and, if unresolved, to submit disputes to binding arbitration in accordance with Provider policy unless prohibited by law.

16. ENTIRE AGREEMENT

This Agreement constitutes the entire understanding between Resident and Provider with respect to its subject matter and supersedes prior oral or written agreements. Any amendment must be in writing and signed by Resident and an authorized representative of Provider.

17. ACKNOWLEDGMENT AND CERTIFICATION

By signing below, Resident (or the individual's authorized representative) certifies that the information provided is true and accurate to the best of their knowledge, that they have had the opportunity to ask questions, and that they understand and accept the terms and conditions of this Agreement.

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