Healthcare Living Contract

HEALTHCARE LIVING CONTRACT

This Healthcare Living Contract (the "Agreement") is entered into between Facility Name: located at Facility Address: and Resident Name: effective as of Admission Date: .

Resident Information

Male Female Other Prefer not to say

Insurance and Billing

The Resident agrees to pay Monthly Fee: due on the day of each month. Security Deposit: . Billing cycle and adjustments will be provided in writing and are subject to the terms below.

Medical History and Care

Services and Resident Responsibilities

Facility will provide the following services as part of this Agreement. Resident acknowledges and agrees that services will be provided subject to medical necessity and facility policies:

Private room and board Meals and dietary accommodations Assistance with activities of daily living (bathing, dressing) Medication administration and monitoring Physical/Occupational therapy coordination Transportation to medical appointments (as arranged)

Resident agrees to follow facility policies, to provide full and accurate medical information, and to notify facility staff promptly of changes in condition. Facility is not responsible for loss of personal property unless otherwise agreed in writing.

Consent, Authorization, and Privacy

By signing this Agreement, Resident authorizes the facility to provide routine and emergency medical care, to administer prescribed medications, and to coordinate with Resident's healthcare providers. Resident further authorizes disclosure of protected health information to the extent necessary to provide care, obtain payment, and conduct health care operations.

I consent to medical and nursing care, including medication administration and nursing assessments as ordered by my physician. I authorize release of medical information to my specified representatives and payors as required for treatment and billing.

Termination, Transfer, and Discharge

This Agreement may be terminated by either party in accordance with the facility's written policies, for nonpayment, for the Resident's change in care needs beyond the facility's capabilities, or for material breach of this Agreement. Facility will provide written notice of transfer or discharge in accordance with applicable standards and will make reasonable efforts to facilitate safe transfer.

Liability, Indemnification, and Insurance

Facility will exercise reasonable care in providing services. Resident understands that the facility does not warrant or guarantee cure of any condition. Resident agrees to hold facility harmless and to indemnify facility for claims arising from Resident's negligent or intentional acts. Resident is encouraged to maintain appropriate personal and medical insurance coverage.

Miscellaneous Provisions

This Agreement constitutes the entire understanding between the parties with respect to the Resident's stay and supersedes prior agreements. Amendments must be in writing signed by both parties. If any provision is held invalid, the remainder shall not be affected. This Agreement shall be governed by the laws of the state in which the facility is located.

Acknowledgment

I acknowledge that I have read and understand this Agreement, that I have received information about facility services, fees, and resident rights, and that I agree to the terms herein.

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